J Shoulder Elbow Surg (2018) 27, e87–e97

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ONLINE ARTICLES

Humeral shaft fractures

Gary F. Updegrove, MDa, Wassim Mourad, MDb, Joseph A. Abboud, MDa,*

a
The Rothman Institute, Philadelphia, PA, USA
b
Division of Orthopedic Surgery, American University of Beirut Medical Center, Beirut, Lebanon

Fractures of the humeral shaft are common injuries with multiple management strategies. Many still regard
nonoperative management as the standard of care; however, as the understanding of these injuries in-
creases, treatment recommendations are also evolving. Fracture pattern, fracture location, and identifiable
patient risk factors may predict poor outcome with nonoperative management, and earlier operative in-
tervention may be recommended. Operative management includes open reduction and internal fixation through
a variety of exposures, intramedullary nail fixation, and external fixation. With increasing rates of shoul-
der arthroplasty, periprosthetic humeral shaft fractures also deserve special consideration.
Level of evidence: Narrative Review
© 2017 Journal of Shoulder and Elbow Surgery Board of Trustees. All rights reserved.
Keywords: Humerus; shaft; fracture; bracing; fixation; periprosthetic

Epidemiology located just distal to the midpoint of the bone on the

Fractures of the humerus comprise approximately 5% to 8%
of all extremity fractures, and shaft fractures account for ap-
proximately 3% of all long-bone fractures.13,70 The incidence
of humeral shaft fractures is approximately 13 per 100,000
persons per year.9
Anatomy
The humeral shaft is commonly defined as the segment distal
to the surgical neck and proximal to the epicondyles.28 Knowl-
edge of the complex neurovascular anatomy of the arm is
imperative to accomplish a safe surgical approach.78 Surgi-
cal landmarks that warrant attention during exposure of the
humeral shaft are the axillary nerve and the brachial artery
proximally, and the median, ulnar, and radial nerves distally.78
The main blood supply of the shaft is via a nutrient artery,
*Reprint requests: Joseph A. Abboud, MD, Shoulder & Elbow Division,
The Sidney Kimmel Medical College at Thomas Jefferson University, 925
Chestnut, 5th Flr, Philadelphia, PA 19107, USA.
E-mail address: joseph.abboud@rothmaninstitute.com (J.A. Abboud).
anteromedial border between the insertion of the coracobra-
chialis and the origin of the brachialis muscle.75
The shaft of the humerus (corpus humeri) is almost cy-
lindrical in its proximal half and then becomes flattened
and triangular distally. It has 3 major surfaces: anterolat-
eral, anteromedial, and posterior.67 The primary areas of
surgical importance are the deltoid tuberosity and the radial
groove. The deltoid tuberosity is an elevation near the middle
of the anterolateral surface, onto which the deltoid muscle
inserts. The radial groove or sulcus (musculospiral groove)
starts distal to the attachment of the lateral head of triceps
on the posterior surface and runs distal and lateral toward
the anterolateral surface. Both the radial nerve and pro-
funda artery pass within this groove.
With a primary radial nerve injury rate ranging from 4%
to 22% in the literature and an iatrogenic surgical injury rate
of almost 3%, the radial nerve deserves special attention.26,48
It arises from the posterior cord of the brachial plexus and
runs anterior to the subscapularis muscle to penetrate the tri-
angular interval in conjunction with the deep brachial artery.
At an average distance of 9.7 to 14.2 cm from the acro-
mion, both structures travel side by side in the radial groove

1058-2746/$ - see front matter © 2017 Journal of Shoulder and Elbow Surgery Board of Trustees. All rights reserved.
https://doi.org/10.1016/j.jse.2017.10.028
e88 G.F. Updegrove et al.

in a plane between the medial and lateral heads of the triceps
muscle. Then, the radial nerve travels adjacent to the poste-
rior aspect of the humerus for 6.5 cm.18 It exits the spiral groove
on average 12.6 cm (range, 10.1-14.8 cm) proximal to the
lateral epicondyle and 18.1 to 20.7 cm proximal to the medial
epicondyle.21,29,40,78 As the radial nerve exits the spiral groove
and penetrates through the lateral intermuscular septum into
the anterior compartment, it is located an average of 10 cm
from the distal articular surface of the elbow but never closer
than 7.5 cm.40 This is the location at which the Holstein-
Lewis fracture can potentially injure the nerve. 25 After
penetrating the lateral intermuscular septum, the radial nerves
gives rise to the posterior antebrachial cutaneous nerve that
course towards the forearm on the posterior aspect of the
septum.78 In the distal arm, the radial nerve courses between
the brachioradialis and the brachialis muscle (Fig. 1).78
The axillary nerve arises from the posterior cord of the
brachial plexus. It courses anterior to the subscapularis muscle,
wraps posteriorly around the surgical neck of the humerus,
and penetrates the quadrangular space, innervating the teres
minor and deltoid muscles. The axillary nerve is traced an
average of 4.3 to 7.4 cm distal to the lateral acromial edge
as it loops around the surgical neck.78
The brachial artery and the median nerve have a joint course
along the humeral shaft. Both are rarely encountered during
humeral shaft exposure. The median nerve arises from the
lateral and medial cords of the brachial plexus and courses
directly medial to the brachial artery along the anterior surface
of the intermuscular septum. Distally, both structures travel
in the interval between the pronator teres and the biceps tendon.78
The ulnar nerve, originating from the medial cord, also
courses anterior to the medial intermuscular septum. It then
crosses posteriorly at the arcade of the Struthers, 8 cm prox-
imal to the medial epicondyle. From there on, the ulnar nerve
travels posterior to the intermuscular septum, behind the medial
epicondyle, and into the cubital tunnel.78
Physical examination
Basic principles are used for patients presenting with humeral
shaft fractures. A skin examination is used to assess for
an open fracture or gross deformity. Then, a vascular
examination is important to confirm the integrity of the radial
and ulnar arteries. A neurologic examination should be per-
formed with emphasis on the function of the radial nerve. Any

Figure 1 Anatomy of the humerus. (A) Posterior view of the neural anatomy of the brachium with reference measurements (in cm) from
prominent anatomic landmarks. The area between the axillary nerve and the spiral groove is the proximal safe zone of the posterior humerus.
The distal safe zone is distal to the spiral groove. (B) Anterior view of the shoulder. Note the relationship of the axillary nerve and the an-
terior circumflex humeral artery to the inferior margin of the subscapularis muscle. During the deltopectoral approach, the “three sisters”
(anterior humeral circumflex artery and its 2 venous comitantes) are often ligated separately to minimize blood loss and gain adequate ex-
posure of the humeral metaphysis. (Reproduced with permission from Zlotolow DA, Catalano LW, Barron OA, Glickel SZ. Surgical exposures
of the humerus. J Am Acad Orthop Surg 2006;14:754-765.)
Humeral shaft fractures e89

Figure 2 Arbeitsgemeinschaft für Osteosynthesefragen (AO)/Orthopaedic Trauma Association (OTA) classification of diaphyseal
fractures. (Reproduced with permission from AO Surgery Reference, www.aosurgery.org. Copyright by AO Foundation, Switzerland.)

neurovascular deficit should be noted before any form of treat-
ment is attempted, whether closed reduction, splinting, casting,
or surgical, and after treatment. Moreover, any concomitant
shoulder, elbow, or forearm injury should be taken into con-
sideration because it may guide the treatment plan. Polytrauma
patients often require surgical fixation to expedite mobilization.
Classification
The widely accepted classification for humeral shaft frac-
tures is the Orthopaedic Trauma Association (OTA)/
Arbeitsgemeinschaft für Osteosynthesefragen (AO) combined
classification, derived from the Müller AO long-bone frac-
tures classification.38 The 3 main types are divided into simple,
wedge, and complex fractures, which are then further
subdivided by pattern. A moderate interobserver and sub-
stantial intraobserver agreement has been shown between
different orthopedic surgeons when humeral shaft fractures
are classified (Fig. 2).37
Two classification systems are commonly used for shoul-
der arthroplasty periprosthetic fractures of the humeral shaft.
The first is the Wright and Cofield classification system, which
is based on the location of the fracture in relation to the tip
of the humeral stem.74 Type A begins at the tip of the stem
and extends proximally, type B begins at the tip of the stem
and extends distally, and type C is completely distal to the
tip of the stem. The other classification system, described by
Campbell et al5 and Williams and Iannotti,73 is based on the
location at which the fracture occurs within the humerus.5,73
Region 1 is the tuberosity, region 2 is metaphyseal, region 3
is the proximal humeral diaphysis, and region 4 is the middle
e90
Figure 3 The Wright and Cofield classification of periprosthetic
fractures of the humerus.74
Type A begins at the tip of the stem and extends proximally. Type
B begins at the tip of the stem and extends distally. Type C is com-
pletely distal to the tip of the stem.
and distal humeral diaphysis. Poor interobserver reliability
and their inability to guide decision making limits these clas-
sification systems (Fig. 3).2
Nonoperative management
Acceptable parameters and the history behind
them
Most surgeons still consider nonsurgical treatment for humeral
shaft fractures the standard of care. In 1966, Klenerman28 re-
viewed 32 patients with humeral shaft fractures and noted that
anterior angulation of 20° or varus of 30° were the limits for
the deformities to become clinically obvious, although without
any compromise in function. These values continue to be
adopted as the acceptable radiographic parameters for bracing.
Variations include the addition of 30° of acceptable valgus
deformity, 15° of acceptable rotational deformity, and short-
ening of less than 3 cm.66 However, despite the ongoing use
of these cutoffs, they lack supporting Level I or II evidence.
Most studies to date have found no well-based correla-
tion between the degree of angular deformity and the functional
outcome. Shields et al66 found no correlation between 0° and
18° sagittal plane residual deformity or between 2° and 27°
of coronal plane residual deformity and the self-reported func-
tional outcomes scores.
Bracing protocol
Before 1977, when Sarmiento et al61 first described the func-
tional brace for humeral shaft fractures, immobilization was
G.F. Updegrove et al.
performed using shoulder spica casts, hanging arm casts,
Thomas arm splints, modified Velpeau dressings, and coap-
tation splints. Although these methods were relatively efficient
in maintaining bony alignment enough for union to occur, they
included the shoulder, elbow, or both joints. Treatment ulti-
mately resulted in proximal or distal stiffness, or both, along
with difficulties in performing activities of daily living.72
Simultaneously, it was established that treatment of humeral
shaft fractures without the use of a rigid fixation led to bone
healing associated with a larger and stronger callus.59 In this
context, the Sarmiento brace was introduced as a solution to
achieve union while maintaining joint motion. Functional
bracing takes advantage of the incompressible fluid effect of
the soft tissues around the fracture site, which maintains a
tight envelope around the fracture fragments. This enve-
lope, aided by the surrounding muscles action vectors, resists
both angular and rotational deforming forces. Shortening,
however, is more dependent on the fracture pattern and the
extent of the initial soft tissue injury and may not be com-
pletely corrected by functional bracing. Strict adherence to
brace use is required to achieve optimal results.12
The treatment of a humeral shaft fracture with function-
al bracing is a stepwise process. At injury, the upper extremity
is stabilized with an above elbow hanging cast or a coapta-
tion splint, spanning from the lateral shoulder, turning 180°
around the elbow, and ending just distal to the axilla. This
immobilization is kept in place for 1 to 2 weeks. On follow-
up, the arm is examined, and a functional brace is applied if
the acute symptoms have subsided and soft tissue condi-
tions are permissive. The functional brace is made of 2 plastic
sleeves held together by Velcro (Velcro BVBA, Manchester,
NH, USA) straps. In its original form, as described by
Sarmiento et al,61 it spans the arm from 5 cm distal to the ax-
illary crease to 5 cm proximal to the olecranon. Some newer
designs include a lateral sleeve that goes over the shoulder,
the importance of which is not yet well defined. The patient
can use the Velcro straps to adjust the width of the brace daily
to accommodate for the gradual decrease in soft tissue swell-
ing and disuse muscle atrophy that may set in during treatment.
The brace should be kept on, and should only be removed
when bathing, until union, which averages 10 to 12 weeks
(Fig. 4).51,61,63
Union rate
The results of functional bracing have been generally favor-
able in the literature. In one of the largest case series to date,
Sarmiento et al63 published the outcomes of 620 patients with
humeral shaft fractures treated with functional bracing. The
nonunion rate was as low as 2% in closed fractures and
6% in open fractures, 87% had less than 16° of varus
angulation after bony healing, and only 2% had a varus de-
formity of more than 25°.63 Papasoulis et al48 reviewed the
literature in 2010 and found an overall union rate of 94.5%,
ranging from 77.4% in 1 study to 100% in 2 other studies.48
Humeral shaft fractures
Figure 4 An over-the-shoulder brace for a humeral fracture.
Functional outcome
This high union rate should additionally be coupled with a
similarly high functional outcome, not inferior to that of op-
erative treatment, to validate conservative management as the
treatment of choice in humeral shaft fractures. Many rela-
tively recent studies have addressed this aspect. Shields et al65
found no statistically significant difference between the op-
erative and nonoperative patients in patient-reported functional
outcome scores. Likewise, Koch et al30 found a 95% healing
rate among 67 fractures treated with bracing. Three patients
had slight limitation in the range of motion, which did not
translate to functional impairment, because all 3 were fully
functional at their jobs.30
The first randomized controlled study comparing surgi-
cal treatment vs. functional bracing for humeral shaft fractures
was reported by Matsunaga et al. 39 Surgery consisted of min-
imally invasive bridge plating through anterior incisions. The
nonunion rates were 0% for the surgical group and 15% for
the conservative group. The surgical group had a higher Dis-
abilities of the Arm, Shoulder and Hand score only at 6
months, with a 6-point difference, whereas a 10-point score
difference is needed to be considered clinically important. Oth-
erwise, there were no differences in the Short Form-36, the
visual analog scale score, or the Constant-Murley score.39
In one of the largest sample studies, Denard et al12 com-
pared 150 patients treated operatively with 63 patients treated
nonoperatively. The rate of nonunion was 20.6% in the
nonoperative group and 8.7% in the surgical group, with a
malunion rate of 12.7% vs. 1.3%, respectively. Radial nerve
palsy occurred in 9.5% of the nonoperatively managed pa-
tients but in only 2.7% of the surgical patients. No difference
e91
in the time to union (4.8 and 4.9 months) or final range of
motion was found between the 2 groups.
Fracture pattern
A literature review for midshaft humeral fractures revealed
a highest risk of nonunion for the transverse fractures (OTA/
AO type A3).15,30,63 Ring et al53 reported the highest nonunion
rate among oblique/spiral fractures, but Matsunaga et al39 found
no correlation between fracture type and union rate.
Koch et al30 reviewed 67 humeral shaft fractures treated
with a functional brace. They reported 9 cases of nonunion
in that series, 5 of which were transverse fractures.30 Ekholm
et al15 found nonunion rate of 18% in type A fractures com-
pared with 4% in type B and 0% in type C. Ali et al1 reviewed
138 humeral shaft fractures treated with bracing. The overall
union rate was of 83%. They also reported a trend for prox-
imal third fractures with an oblique to have higher nonunion
rates than other types and location. Comminuted fractures had
an overall higher union rate (89%) irrespective of location.1
Ring et al53 reviewed nonunion cases that were treated with
bracing and found that the fractures that were prone to non-
union were the proximal and middle third fractures as opposed
to the distal third fractures and oblique/spiral fractures as
opposed to transverse fractures. The later finding is the op-
posite of what others have found, possibly because of the small
sample size of 32 in their series.15,30,53,63 In the Matsunaga ran-
domized controlled trial, no differences were found for the
type or location of the fractures in subgroup analysis in the
union rate between surgical and nonsurgical groups.39 As for
healing time after functional bracing, Sarmiento et al63 found
a median of 12 weeks for transverse fractures, 10 weeks for
oblique fractures, 11 weeks for comminuted fractures, and
12 weeks for segmental fractures.
The reason different fracture patterns have varying union
rates is uncertain.1 Transverse fracture patterns might be more
prone to nonunion than oblique/spiral patterns, due to less
bone contact area. In contrast, muscle and soft tissue invagi-
nation into the fracture site in oblique/spiral fractures could
be the cause of nonunion in these fractures compared with
transverse fractures.53
Fracture location
Proximal third fractures
Fractures of the proximal third of the humeral shaft are no-
torious for having higher nonunion rates than the distal two-
thirds, as evidenced by many studies.1,58,69 Ali et al1 reviewed
138 humeral shaft fractures treated with bracing, and the overall
union rate was 83%. Subgroup analysis showed lower union
rate in the proximal third fractures (76%) than in middle (88%)
and distal third (85%) fractures. They also reported a trend
for oblique pattern proximal third fractures to have a higher
nonunion rate than other types and location.1 Rutgers et al58
e92
reviewed 49 patients treated conservatively by a single surgeon.
The proximal third fracture had a nonunion rate of 29% com-
pared with 4% in the middle third and 0% in the distal third;
however, these difference did not reach clinical significant
because of the small sample size.58 Toivanen et al69 had an
even higher proximal third nonunion rate of 54% (7 of 13).
A speculated cause of the higher proximal third non-
union rate is the pull of the deltoid and the pectoralis major
along with muscle interposition at the fracture site.58
Distal third fractures
Distal third humeral fractures differ from the proximal two-
thirds in that many surgeons are hesitant about conservative
treatment. Surgical advocates claim that these fractures are
at high risk of varus malalignment and, when treated con-
servatively, are at risk for iatrogenic radial nerve injury during
reduction in a brace. In addition, these fractures will result
in difficulties with daily living and stiffness at the level of
the elbow, with ongoing pain until union. Those who rec-
ommend bracing for these fractures are supported by the lack
of evidence favoring surgical treatment and by similar func-
tional outcomes.54
Sarmiento et al60 assessed the results of distal third humeral
fractures treated with bracing. The union rate was of 96%.
Varus angulation averaged 9° in 81%, and only 3% had a valgus
deformity. Posterior angulation was present in 39% of the pa-
tients, ranging from 3° to 22°, and anterior angulation was
found in 41% of the patients, ranging from 1° to 30°. However,
these deformities did not translate into functional impair-
ment in this group. Forty-five percent of patients lost between
5° and 45° of shoulder external rotation. Elbow flexion loss
was between 5° and 25° in 26%, and elbow extension loss
was between 5° and 25° in 24%.60 In the Ekholm et al15 series,
nonunion after bracing occurred at a rate of 7% for proximal
third fractures, 17% for middle third fractures, and only 5%
for distal third fractures. When only type A fractures were
selected, nonunion rates were of 20% in the proximal third,
19% in the middle third, and 13% in the distal third.
Jawa et al26 reviewed 51 patients with distal third frac-
tures. In the operative group, 14% had new postoperative radial
nerve palsy, whereas no new-onset radial nerve palsy was seen
in the bracing group. The average elbow flexion loss was 3°
in the operative group and 6° in the bracing group. This dif-
ference was not significant, and the fractures all of those who
were braced healed. They concluded that operative treat-
ment is more predictable in malalignment outcome, which
may not be clinically important.26 In another study dealing
with distal third fractures, Pehlivan et al51 reviewed 21 iso-
lated closed distal third humeral fractures treated with
functional bracing. The union rate was 100% at an average
of 12 weeks. The average varus angulation was 8° in 8 pa-
tients. Shortening averaged 10 mm in 10 patients. No clinically
significant range of motion loss was found at a mean follow-
up of 39 months.51
G.F. Updegrove et al.
Holstein-Lewis
The Holstein-Lewis fracture is a displaced spiral fracture of
the distal humeral shaft, with proximal and radial displace-
ment of the distal fragment, that could potentially injure the
radial nerve as it passes the lateral intramuscular septum. When
first described in 1966, it was postulated that primary open
reduction and internal fixation is the treatment of choice and
that closed reduction is contraindicated.25
However, with time it has become clearer that even the
Holstein-Lewis fractures can be managed conservatively
without added risk. A review of the Stockholm registry of 361
patients with humeral shaft fractures showed the incidence
of a Holstein-Lewis fracture was 7.5%. Patients tended to be
younger and had sustained high-energy trauma. Radial nerve
palsy was present in 22% (6 of 27) of these patients and in
8% (27 of 344) in the non-Holstein-Lewis humeral shaft frac-
tures types. Among the patients with a Holstein-Lewis fracture,
26% were treated surgically and 74% were treated conser-
vatively. The fractures of all conservatively treated patient went
into union. All 6 patients with associated radial nerve palsy
recovered; of whom, 2 were treated nonoperatively and four
surgically.
At a mean follow-up of 6.3 years, there were no differ-
ences between the operative and the nonoperative groups in
functional outcome and range of motion, notably at the elbow.
These results thus refuted the concept that a Holstein-Lewis
fracture is an absolute indication for surgery, regardless of
presence of radial nerve palsy.14
Other factors
Neuhaus et al43 reviewed 79 patients with AO/OTA type A2
and A3 middle humeral fractures. The union rate of the group
was 80%. They analyzed the factors that increased the risk
of fracture mobility at 6 weeks of functional bracing. They
found that smoking increased the risk by 6 times, female sex
by 5 times, and each mm of gap at the fracture site on initial
radiographs by 40%. Angular deformities did not correlate
with fracture mobility (Table I).43
Operative indications
Operative management of humeral shaft fractures may be in-
dicated in a variety of scenarios. Operative stabilization should
be used when an acceptable alignment cannot be achieved
Table I Patient and fracture characteristics more prone to
nonunion
Proximal third fractures
Oblique pattern in the proximal third
Smoking
Female sex
Gap size at the fracture site
Humeral shaft fractures
in a brace. With cases of open fractures associated with severe
soft tissue injury or high-velocity gunshot injuries, often an
operative débridement is performed, and fixation may also
be performed while the fracture is exposed. In low-velocity
gunshot injuries, however, the type of management is dic-
tated by the fracture characteristics, and even when the fracture
is associated with radial nerve palsy, conservative treatment
is still an option.63 Given the high rate of spontaneous re-
covery of radial nerve palsy in closed humeral shaft fractures,
early nerve exploration and fracture fixation is not indi-
cated. However, early nerve exploration with osteosynthesis
is agreed upon when one of the following factors is present:
open fracture, vascular injury, high-velocity gunshot injury,
severe soft tissue injury, or manipulation induced secondary
radial nerve injury.3,31,45,52,55 A vascular injury requiring repair
is an absolute indication for operative management, because
rigid fixation protects the vascular anastomosis.50
Brachial plexus injuries are considered an indication for
operative management, because a nonstable fracture delays
rehabilitation and bracing carries a high nonunion rate (45%).4
A pathologic fracture is also in an indication for surgical
treatment.42 Comminuted and segmental fractures have a po-
tential for healing with bracing and thus can only be considered
as a relative indication for operative management.60 Al-
though bilateral humeral fractures have been considered an
absolute indication for surgery, bracing is still possible if the
patient is ambulatory and is able to perform activities of daily
living while wearing the brace.62,76 Polytrauma is a relative
indication for fixation, because this potentially allows for im-
proved mobility of these patients by use of their upper limb.
Immediate weight bearing has been shown to be safe without
an increased rate of nonunion or malunion after plate fixa-
tion of the humeral shaft.68
Cases in which the humeral shaft fracture also has prox-
imal or distal intra-articular extension and the intra-articular
fracture meets operative indications, the humeral shaft frac-
ture is often fixed in the same setting. Similarly, when an
ipsilateral forearm fracture is present, termed a floating-
elbow, fixation of the humeral shaft may also be performed
(Table II).
Open reduction and internal fixation
Many consider open reduction and plate fixation as the pre-
ferred method for operative stabilization of humeral shaft
fractures. Among its advantages are the multiple surgical ex-
posures that can be selected based on surgeon preference as
well as factors such as fracture pattern, soft tissue wounds,
or the need to address the radial nerve. Many of the ap-
proaches may also be extended to address concomitant
fractures around the shoulder and elbow.
The anterolateral exposure is a distal extension of the
deltopectoral approach along the lateral side of the biceps.
After the biceps is reflected medially, the deep dissection
splits the brachialis between the middle and lateral thirds of
e93
Table II Indication for operative management of humeral shaft
fractures
Indications Relative indications
Acceptable alignment cannot Low velocity gunshot injury
be achieved with brace Polytrauma
Skin condition precludes Bilateral humerus fractures
bracing (burns, etc.) Open fractures
High-velocity gunshot injury Comminuted fractures
Open fractures with severe soft Segmental fractures
tissue injury
Vascular injury requiring repair
Brachial plexus injury
Pathologic fractures
Radial nerve injury after
manipulation
Intra-articular fractures
Floating elbow
the muscle belly on the anterior aspect of the humerus,
exploiting the dual innervation of this muscle. The lateral
antebrachial nerve must be protected distally as it exits
between the biceps and brachialis, as well as the radial
nerve between the brachialis and brachioradialis. This ap-
proach allows for excellent exposure of the proximal and
middle humeral shaft.
For distal fractures, a posterior approach may be more ad-
vantageous to expose both the shaft and the elbow. Posterior
exposure also allows the radial nerve to be visualized prox-
imally, providing the ability to place hardware underneath the
nerve at the spiral groove if proximal fixation is required. There
are several deep exposures with a posterior approach, al-
though most often it is performed with medial and lateral
paratricipital windows or the triceps is split in line with its
fibers and tendon. The paratricipital windows afford excel-
lent exposure of the distal fragment, allow for periarticular
fixation of the distal humerus, and are often preferred because
it avoids dissection into the triceps muscle belly. Gerwin et
al18 found that 55% of the distal humerus could be visual-
ized using a paratricipital exposure without mobilization of
the radial nerve. Reflecting the triceps medially increased the
exposure to 94% of the humerus, providing excellent prox-
imal and distal exposure. The radial nerve must be identified
as it exits the spiral groove and pierces the intramuscular
septum and then mobilized and protected before the triceps
is reflected medially. The triceps-splitting approach is per-
formed between the long and lateral head of the triceps,
allowing deep exposure to the medial head and humeral shaft.
This provides direct exposure of the spiral groove, where the
radial nerve can then be protected. With a triceps-splitting
approach, 76% of the humerus could be visualized with radial
nerve mobilization.18
A variety of options are available when plates are se-
lected for fixation. Although large fragment plates, both broad
and narrow, are often used, small fragment plates and some-
times even minifragment plates may also have a role. Adhering
e94 G.F. Updegrove et al.

to basic AO principles of fracture management is important

when plate fixation is performed. Plates can be used for direct
compression fracture fixation, neutralization of lag screw
interfragmentary fixation, or in a bridging fashion. Direct re-
duction with absolute stability and fixation is ideal when the
morphology of the fracture allows. A variety of reduction tools
and clamps are available to aid with provisional reduction and
stabilization. Smaller bone fragments also may be reduced
and stabilized with small-fragment or minifragment screws.
With significant comminution that is not amendable to direct
reduction, the segment should be bridged. If severe commi-
nution with nonviable fragments or bone loss is present, the
humerus can be shortened to allow bony opposition and
improve healing. This is better tolerated in the upper extrem-
ity then the lower, although some muscle weakness may result
from significant shortening.
Interest in dual plating of humeral shaft fractures has led
to a number of recent biomechanical studies to demonstrate
its effectiveness.27,32,33 Dual plates may be beneficial to improve
stability of the construct and also to assist with provisional
fixation of the reduction. Large-fragment plates, both broad
and narrow, are often used; however, small-fragment plates
can be advantageous, especially for small patients, as well
as dual plating. A finite element study showed that dual plating Figure 5 Humeral shaft fracture treated with minifragment plate
also improves weight-bearing tolerance.32 Immediate weight for provisional fixation with large fragment plate added for stability.
bearing has been shown to be safe after open reduction and
plate fixation.68
Locking screws have proven to be of significant advance- significantly increased the risk of shoulder complications and
ment in plate fixation; however, their use may not be as reoperation.
pronounced in humeral shaft fracture management as it is with A concern with intramedullary nailing is increased shoul-
periarticular fractures. Biomechanical studies in synthetic and der pain and increased reoperation rates.6,36,56,71 Various entry
cadaveric models have shown locking screws do not offer bio- portals have been proposed to address the increased inci-
mechanical benefit in plate fixation of humeral shaft fractures, dence of shoulder pain after antegrade intramedullary nailing
and additional locking screws in osteoporotic bone do not of the humerus, which is thought to occur due to injury to
improve stability (Fig. 5).22,46 the rotator cuff. These include more medial and lateral portals
to avoid the insertion of the rotator cuff tendon as well ac-
cessing the proximal humerus through the rotator interval.8,49
Intramedullary nail fixation This is sometimes performed in conjunction with a biceps
tenodesis, which has also been proposed as a source of pain
Plate fixation does allow for direct reduction and compres- after intramedullary nailing.8 Retrograde intramedullary nailing
sion, but intramedullary fixation has the advantages of of the humerus may also be performed, which avoids injury
providing a load-sharing implant while preserving the peri- to the shoulder altogether. A prospective randomized study
osteal blood supply and minimizing the disruption of the of antegrade compared with retrograde locked nailing of the
biology at the fracture site. Although nonlocked devices, such humerus demonstrated a longer time for return of function
as Kirschner wires, flexible nails, and Enders nails, have largely of the shoulder for antegrade; however, longer return to func-
been abandoned due to their inability to control rotation, there tion of the elbow was noted in the retrograde group.7
remains an interest and use of intramedullary locked devices. A recent systematic review evaluated minimally invasive
Locked intramedullary nails have been shown to have similar plating vs. open reduction and plate fixation or intramedul-
union rates to plate fixation and also similar rates of radial lary nailing of humeral shaft fractures. The study showed that
nerve palsy.19,23,35,36,47,71,77 minimally invasive techniques had better outcomes with lower
Zhao et al77 performed a systematic review of meta- complication rates, although poor reporting of randomiza-
analyses of intramedullary nail fixation compared with plate tion and significant bias in the primary studies may limit the
fixation for humeral shaft fractures. The review included 7 significance of this conclusion.24
meta-analyses of randomized controlled trials. Their results A review of the American Board of Orthopaedic Surgery
analysis found no difference in the rate of union, radial nerve case database demonstrated a decline in the use of intramed-
injury, or infection. Intramedullary nail use, however, ullary nails for treatment of humeral shaft fractures from 2004
Humeral shaft fractures e95

to 2013.19 However, this study also demonstrated decreased

complications in the intramedullary nail groups and no sig-
nificant difference in nonunion rate.

External fixation

External fixation remains an important option to consider in

certain situations such as polytrauma patients, bilateral frac-
tures, and severe fracture comminution or soft tissue injury.
It is important to be aware of the neurovascular structures at
risk, most notably the radial nerve, during pin insertion in
the humerus. There are multiple described techniques avail-
able for review of safe placement of pins in the upper
extremity.17,57 Direct visualization of the radial nerve during
distal pin placement is recommended. Scaglione et al64 ret-
rospectively reviewed 85 shaft or extra-articular distal third
humeral fractures treated definitively with eternal fixation. They
reported a healing rate of 97.6% at an average of 12 weeks.
There were no iatrogenic radial nerve injuries from pin place-
ment, although there was 1 case of neurapraxia, which
resolved. Complications included 1 delayed union, 1 refrac-
ture, and 5 that healed with residual angular deformity.
Figure 6 Humeral fracture at the tip of the arthroplasty stem
Periprosthetic fractures managed with hybrid screw and cable fixation to a plate.

Periprosthetic fractures in the humerus remain a challeng-

ing problem. Current evidence on treatment and outcome of
these fractures is limited, although as rates of shoulder ar-
throplasty rise, the incidence of periprosthetic fractures is
expected to rise as well.10 The goals of treatment are to achieve
fracture union while maintaining the stability of the prosthe-
sis, preserve the glenohumeral motion, and restore shoulder
function. Decision making should be based on the location
of the fracture, the timing of the fracture, and the stability
of the components. 20 Treatment strategies vary from
nonoperative management, to open reduction and internal fix-
ation, to revision arthroplasty.2,16,34,41 Indications for treatment
mirror those of humeral shaft fractures without a prosthe-
sis. Nonoperative management can be attempted if the
prosthesis is stable and acceptable alignment can be achieved
with functional bracing.44 An unstable prosthesis should be
revised, often with a longer stem, and with consideration of
cortical strut allograft or additional fixation, depending on bone
quality (Fig. 6).11
Summary
fixation is often the preferred method, although intramedul-
lary fixation and even external fixation may prove
advantageous in certain scenarios.
Disclaimer
Joseph A. Abboud receives research support from DePuy,
Zimmer, Tornier, Integra, OREF, DJO, and Orthospace;
is a paid consultant for Tornier, Cayenne, DJO, and Globus;
receives royalties from Integra, Wolters Kluwer Health–
Lippincott Williams & Wilkins, Cayenne, and DJO; receives
stock options from and is on the Scientific Advisory Board
of MinInvasive; receives stock options from Aevumed; and
is on the Board of Directors of MASES.
The other authors, their immediate families, and any
research foundations with which they are affiliated have
not received any financial payments or other benefits from
any commercial entity related to the subject of this article.

Humeral shaft fractures can often be successfully managed

nonoperatively with splints and bracing. Radial nerve inju-
ries are not uncommon, both from the injury as well as
iatrogenic injuries from the treatment. Acceptable radio-
graphic parameters are not well supported and do not seem
to correlate with functional outcome. In certain cases, a more
predictable result for alignment and union may be achieved
with operative intervention. Open reduction and plate
References
1. Ali E, Griffiths D, Obi N, Tytherleigh-Strong G, Van Rensburg L.
Nonoperative treatment of humeral shaft fractures revisited. J Shoulder
Elbow Surg 2015;24:210-4. http://dx.doi.org/10.1016/j.jse.2014.05.009
2. Andersen JR, Williams CD, Cain R, Mighell M, Frankle M. Surgically
treated humeral shaft fractures following shoulder arthroplasty. J Bone
Joint Surg Am 2013;95:9-18. http://dx.doi.org/10.2106/JBJS.K.00863
e96
3. Bishop J, Ring D. Management of radial nerve palsy associated with
humeral shaft fracture: a decision analysis model. J Hand Surg Am
2009;34:991-6, e1. http://dx.doi.org/10.1016/j.jhsa.2008.12.029
4. Brien WW, Gellman H, Becker V, Garland DE, Waters RL, Wiss DA.
Management of fractures of the humerus in patients who have an injury
of the ipsilateral brachial plexus. J Bone Joint Surg 1990;72:1208-
10.
5. Campbell JT, Moore RS, Iannotti JP, Norris TR, Williams GR.
Periprosthetic humeral fractures: mechanisms of fracture and treatment
options. J Shoulder Elbow Surg 1998;7:406-13.
6. Changulani M, Jain UK, Keswani T. Comparison of the use of the
humerus intramedullary nail and dynamic compression plate for the
management of diaphyseal fractures of the humerus. A randomised
controlled study. Int Orthop 2006;31:391-5. http://dx.doi.org/10.1007/
s00264-006-0200-1
7. Cheng HR, Lin J. Prospective randomized comparative study of antegrade
and retrograde locked nailing for middle humeral shaft fracture. J Trauma
2008;65:94-102. http://dx.doi.org/10.1097/TA.0b013e31812eed7f
8. Christ AB, Gausden EB, Warner SJ, Nellestein AM, Thacher R,
Lorich DG. Rotator cuff-sparing approach for antegrade humeral
nailing with biceps tenodesis: a technical trick with clinical implications.
J Orthop Trauma 2016;31:e60-5. http://dx.doi.org/10.1097/BOT
.0000000000000684
9. Court-Brown CM, Caesar B. Epidemiology of adult fractures: a review.
Injury 2006;37:691-7. http://dx.doi.org/10.1016/j.injury.2006.04.130
10. Day JS, Lau E, Ong KL, Williams GR, Ramsey ML, Kurtz SM.
Prevalence and projections of total shoulder and elbow arthroplasty in
the United States to 2015. J Shoulder Elbow Surg 2010;19:1115-20.
http://dx.doi.org/10.1016/j.jse.2010.02.009
11. Dehghan N, Chehade M, McKee MD. Current perspectives in the
treatment of periprosthetic upper extremity fractures. J Orthop
Trauma 2011;25(Suppl 2):S71-6. http://dx.doi.org/10.1097/BOT
.0b013e31821acfa5
12. Denard A, Richards JE, Obremskey WT, Tucker MC, Floyd M, Herzog
GA. Outcome of nonoperative vs operative treatment of humeral shaft
fractures: a retrospective study of 213 patients. Orthopedics 2010;33.
http://dx.doi.org/10.3928/01477447-20100625-16
13. Ekholm R, Adami J, Tidermark J, Hansson K, Törnkvist H, Ponzer S.
Fractures of the shaft of the humerus. An epidemiological study of 401
fractures. J Bone Joint Surg Br 2006;88:1469-73. http://dx.doi.org/
10.1302/0301-620X.88B11.17634
14. Ekholm R, Ponzer S, Törnkvist H, Adami J, Tidermark J. The Holstein-
Lewis humeral shaft fracture: aspects of radial nerve injury, primary
treatment, and outcome. J Orthop Trauma 2008;22:693-7. http://dx.
doi.org/10.1097/BOT.0b013e31818915bf
15. Ekholm R, Tidermark J, Törnkvist H, Adami J, Ponzer S. Outcome after
closed functional treatment of humeral shaft fractures. J Orthop Trauma
2006;20:591-6. http://dx.doi.org/10.1097/01.bot.0000246466.01287
.04
16. García-Fernández C, Lópiz-Morales Y, Rodríguez A, López-Durán L,
Martínez FM. Periprosthetic humeral fractures associated with reverse
total shoulder arthroplasty: incidence and management. Int Orthop
2015;39:1965-9. http://dx.doi.org/10.1007/s00264-015-2972-7
17. Gausepohl T, Koebke J, Pennig D, Hobrecker S, Mader K. The
anatomical base of unilateral external fixation in the upper limb. Injury
2000;31(Suppl 1):11-20.
18. Gerwin M, Hotchkiss RN, Weiland AJ. Alternative operative exposures
of the posterior aspect of the humeral diaphysis with reference to the
radial nerve. J Bone Joint Surg Am 1996;78:1690-5.
19. Gottschalk MB, Carpenter W, Hiza E, Reisman W, Roberson J. Humeral
shaft fracture fixation: incidence rates and complications as reported by
American Board of Orthopaedic Surgery Part II Candidates. J Bone Joint
Surg Am 2016;98:e71. http://dx.doi.org/10.2106/JBJS.15.01049
20. Gregory JM, Hsu J, Galatz LM. Periprosthetic humeral fractures
in shoulder arthroplasty. Semin Arthroplasty 2014;25:59-63.
http://dx.doi.org/10.1053/j.sart.2014.02.009
G.F. Updegrove et al.
21. Guse TR, Ostrum RF. The surgical anatomy of the radial nerve around
the humerus. Clin Orthop Relat Res 1995;(320):149-53.
22. Hak DJ, Althausen P, Hazelwood SJ. Locked plate fixation of
osteoporotic humeral shaft fractures: are two locking screws per segment
enough? J Orthop Trauma 2010;24:207-11. http://dx.doi.org/10
.1097/BOT.0b013e3181bdd1da
23. Hashib G. Management of humeral shaft fracture: a comparative study
between interlocking nail and dynamic compression plating. Int J Res
Orthop 2016;2:40-7. http://dx.doi.org/10.18203/issn.2455-4510
.IntJResOrthop20161457
24. Hohmann E, Glatt V, Tetsworth K. Minimally invasive plating versus
either open reduction and plate fixation or intramedullary nailing of
humeral shaft fractures: a systematic review and meta-analysis of
randomized controlled trials. J Shoulder Elbow Surg 2016;25:1634-42.
http://dx.doi.org/10.1016/j.jse.2016.05.014
25. Holstein A, Lewis GF. Fractures of the humerus with radial-nerve
paralysis. J Bone Joint Surg Am 1963;45:1382-8.
26. Jawa A, McCarty P, Doornberg J, Harris M, Ring D. Extra-articular
distal-third diaphyseal fractures of the humerus. A comparison of
functional bracing and plate fixation. J Bone Joint Surg Am
2006;88:2343-7. http://dx.doi.org/10.2106/JBJS.F.00334
27. Karakasli A, Basci O, Ertem F, Sekik E, Havitcioglu H. Dual plating
for fixation of humeral shaft fractures: a mechanical comparison of
various combinations of plate lengths. Acta Orthop Traumatol Turc
2016;50:432-6. http://dx.doi.org/10.1016/j.aott.2016.07.002
28. Klenerman L. Fractures of the shaft of the humerus. J Bone Joint Surg
Br 1966;48:105-11.
29. Klepps S, Auerbach J, Calhon O, Lin J, Cleeman E, Flatow E. A
cadaveric study on the anatomy of the deltoid insertion and its
relationship to the deltopectoral approach to the proximal humerus. J
Shoulder Elbow Surg 2004;13:322-7. http://dx.doi.org/10.1016/
j.jse.2003.12.014
30. Koch PP, Gross DF, Gerber C. The results of functional (Sarmiento)
bracing of humeral shaft fractures. J Shoulder Elbow Surg 2002;11:143-
50. http://dx.doi.org/10.1067/mse.2002.121634
31. Korompilias AV, Lykissas MG, Kostas-Agnantis IP, Vekris MD,
Soucacos PN, Beris AE. Approach to radial nerve palsy caused by
humerus shaft fracture: is primary exploration necessary? Injury
2013;44:323-6. http://dx.doi.org/10.1016/j.injury.2013.01.004
32. Kosmopoulos V, Luedke C, Nana AD. Dual small fragment plating
improves screw-to-screw load sharing for mid-diaphyseal humeral
fracture fixation: a finite element study. Technol Health Care 2015;23:83-
92. http://dx.doi.org/10.3233/THC-140875
33. Kosmopoulos V, Nana AD. Dual plating of humeral shaft fractures:
orthogonal plates biomechanically outperform side-by-side plates. Clin
Orthop Relat Res 2013;472:1310-7. http://dx.doi.org/10.1007/
s11999-013-3379-7
34. Kurowicki J, Momoh E, Levy JC. Treatment of periprosthetic humerus
fractures with open reduction and internal fixation. J Orthop Trauma
2016;30:e369-74. http://dx.doi.org/10.1097/BOT.0000000000000646
35. Kurup H, Hossain M, Andrew JG. Dynamic compression plating versus
locked intramedullary nailing for humeral shaft fractures in adults.
Cochrane Database Syst Rev 2011;(6):CD005959. http://dx.doi.org/10
.1002/14651858.CD005959.pub2
36. Ma J, Xing D, Ma X, Gao F, Wei Q, Jia H, et al. Intramedullary nail
versus dynamic compression plate fixation in treating humeral shaft
fractures: grading the evidence through a meta-analysis. PLoS One
2013;8:e82075. http://dx.doi.org/10.1371/journal.pone.0082075
37. Mahabier KC, Van Lieshout EM, Van Der Schaaf BC, Roukema GR,
Punt BJ, Verhofstad MH, et al. Reliability and reproducibility of the
OTA/AO classification for humeral shaft fractures. J Orthop Trauma
2017;31:e75-80. http://dx.doi.org/10.1097/BOT.0000000000000738
38. Marsh JL, Slongo TF, Agel J, Broderick JS, Creevey W, DeCoster TA,
et al. Fracture and dislocation classification compendium—2007:
Orthopaedic Trauma Association classification, database and outcomes
committee. J Orthop Trauma 2007;21(10 Suppl):S1-6.
Humeral shaft fractures
39. Matsunaga FT, Tamaoki MJ, Matsumoto MH, Netto NA, Faloppa F,
Belloti JC. Minimally invasive osteosynthesis with a bridge plate versus
a functional brace for humeral shaft fractures: a randomized controlled
trial. J Bone Joint Surg Am 2017;99:583-92. http://dx.doi.org/10.2106/
JBJS.16.00628
40. McCann PA, Smith GC, Clark D, Amirfeyz R. The tricipital
aponeurosis—a reliable soft tissue landmark for humeral plating. Hand
Surg 2015;20:53-8. http://dx.doi.org/10.1142/S0218810415500070
41. Mineo GV, Accetta R, Franceschini M, Pedrotti Dell’Acqua G, Calori
GM, Meersseman A. Management of shoulder periprosthetic fractures:
our institutional experience and review of the literature. Injury
2013;44(Suppl 1):S82-5. http://dx.doi.org/10.1016/S0020-1383
(13)70018-4
42. Muramatsu K, Ihara K, Iwanagaa R, Taguchi T. Treatment of metastatic
bone lesions in the upper extremity: indications for surgery. Orthopedics
2010;33:807.
43. Neuhaus V, Menendez M, Kurylo JC, Dyer GS, Jawa A, Ring D. Risk
factors for fracture mobility six weeks after initiation of brace treatment
of mid-diaphyseal humeral fractures. J Bone Joint Surg Am
2014;96:403-7. http://dx.doi.org/10.2106/JBJS.M.00089
44. Neviaser AS, Flatow EL. Periprosthetic humeral fractures: you’re
breakin’ my heart. Semin Arthroplasty 2011;22:48-50. http://dx.doi
.org/10.1053/j.sart.2011.01.012
45. Niver GE, Ilyas AM. Management of radial nerve palsy following
fractures of the humerus. Orthop Clin North Am 2013;44:419-24, x.
http://dx.doi.org/10.1016/j.ocl.2013.03.012
46. O’Toole RV, Andersen RC, Vesnovsky O, Alexander M, Topoleski LD,
Nascone JW, et al. Are locking screws advantageous with plate fixation
of humeral shaft fractures? A biomechanical analysis of synthetic and
cadaveric bone. J Orthop Trauma 2008;22:709-15. http://dx.doi.org/10
.1097/BOT.0b013e31818df8cb
47. Ouyang H, Xiong J, Xiang P, Cui Z, Chen L, Yu B. Plate versus
intramedullary nail fixation in the treatment of humeral shaft fractures:
an updated meta-analysis. J Shoulder Elbow Surg 2013;22:387-95.
http://dx.doi.org/10.1016/j.jse.2012.06.007
48. Papasoulis E, Drosos GI, Ververidis AN, Verettas DA. Functional bracing
of humeral shaft fractures. A review of clinical studies. Injury
2010;41:e21-7. http://dx.doi.org/10.1016/j.injury.2009.05.004
49. Park JY, Pandher DS, Chun JY, Lee ST. Antegrade humeral nailing
through the rotator cuff interval: a new entry portal. J Orthop Trauma
2008;22:419-25. http://dx.doi.org/10.1097/BOT.0b013e318173f751
50. Paryavi E, Pensy RA, Higgins TF, Chia B, Eglseder WA. Salvage of
upper extremities with humeral fracture and associated brachial artery
injury. Injury 2014;45:1870-5. http://dx.doi.org/10.1016/j.injury
.2014.08.038
51. Pehlivan O. Functional treatment of the distal third humeral shaft
fractures. Arch Orthop Trauma Surg 2002;122:390-5. http://dx.doi.org/
10.1007/s00402-002-0403-x
52. Prodromo J, Goitz RJ. Management of radial nerve palsy associated with
humerus fracture. J Hand Surg Am 2013;38:995-8, quiz 998.
http://dx.doi.org/10.1016/j.jhsa.2013.02.003
53. Ring D, Chin K, Taghinia AH, Jupiter JB. Nonunion after functional
brace treatment of diaphyseal humerus fractures. J Trauma
2007;62:1157-8. http://dx.doi.org/10.1097/01.ta.0000222719.52619.2c
54. Ring D, Jawa A, Cannada L. Clinical faceoff: are distal-third diaphyseal
humerus fractures best treated nonoperatively? Clin Orthop Relat Res
2016;474:310-4. http://dx.doi.org/10.1007/s11999-015-4636-8
55. Rocchi M, Tarallo L, Mugnai R, Adani R. Humerus shaft fracture
complicated by radial nerve palsy: is surgical exploration necessary?
Musculoskelet Surg 2016;100(Suppl 1):53-60. http://dx.doi.org/10.1007/
s12306-016-0414-3
56. Rommens PM, Kuechle R, Bord T, Lewens T, Engelmann R, Blum J.
Humeral nailing revisited. Injury 2008;39:1319-28. http://dx.doi
.org/10.1016/j.injury.2008.01.014
57. Ruland WO. Is there a place for external fixation in humeral shaft
fractures? Injury 2000;31(Suppl 1):27-34.
e97
58. Rutgers M, Ring D. Treatment of diaphyseal fractures of the humerus
using a functional brace. J Orthop Trauma 2006;20:597-601.
http://dx.doi.org/10.1097/01.bot.0000249423.48074.82
59. Rüedi T, Moshfegh A, Pfeiffer KM, Allgöwer M. Fresh fractures of the
shaft of the humerus—conservative or operative treatment? Reconstr Surg
Traumatol 1974;14:65-74.
60. Sarmiento A, Horowitch A, Aboulafia A, Vangsness CT. Functional
bracing for comminuted extra-articular fractures of the distal third of
the humerus. J Bone Joint Surg Br 1990;72:283-7.
61. Sarmiento A, Kinman PB, Galvin EG, Schmitt RH, Phillips JG.
Functional bracing of fractures of the shaft of the humerus. J Bone Joint
Surg Am 1977;59:596-601.
62. Sarmiento A, Latta LL. Fractures of the humeral diaphysis. In: Functional
fracture bracing: tibia, humerus, and ulna. Heidelberg: Springer; 1995.
p. 141-203.
63. Sarmiento A, Zagorski JB, Zych GA, Latta LL, Capps CA. Functional
bracing for the treatment of fractures of the humeral diaphysis. J Bone
Joint Surg Am 2000;82:478-86.
64. Scaglione M, Fabbri L, Dell’Omo D, Goffi A, Guido G. The
role of external fixation in the treatment of humeral shaft
fractures: a retrospective case study review on 85 humeral
fractures. Injury 2015;46:265-9. http://dx.doi.org/10.1016/j.injury
.2014.08.045
65. Shields E, Sundem L, Childs S, Maceroli M, Humphrey C, Ketz J, et al.
Factors predicting patient-reported functional outcome scores after
humeral shaft fractures. Injury 2015;46:693-8. http://dx.doi.org/10.1016/
j.injury.2015.01.027
66. Shields E, Sundem L, Childs S, Maceroli M, Humphrey C, Ketz JP,
et al. The impact of residual angulation on patient reported functional
outcome scores after non-operative treatment for humeral shaft fractures.
Injury 2015;47:1-5. http://dx.doi.org/10.1016/j.injury.2015.12.014
67. Lambert SM. Shoulder girdle and arm. In: Standing S, editor.
Gray’s anatomy. New York: Elsevier Limited; 2016. p. 797-
836.e1.
68. Tingstad EM, Wolinsky PR, Shyr Y, Johnson KD. Effect of immediate
weightbearing on plated fractures of the humeral shaft. J Trauma
2000;49:278-80.
69. Toivanen JA, Nieminen J, Laine HJ, Honkonen SE, Järvinen MJ.
Functional treatment of closed humeral shaft fractures. Int Orthop
2005;29:10-3. http://dx.doi.org/10.1007/s00264-004-0612-8
70. Volgas DA, Stannard JP, Alonso JE. Nonunions of the humerus. Clin
Orthop Relat Res 2004;419:46-50.
71. Wali MG, Baba AN, Latoo IA, Bhat NA, Baba OK, Sharma S. Internal
fixation of shaft humerus fractures by dynamic compression plate or
interlocking intramedullary nail: a prospective, randomised study.
Strategies Trauma Limb Reconstr 2014;9:133-40. http://dx.doi.org/
10.1007/s11751-014-0204-0
72. Walker M, Palumbo B, Badman B, Brooks J, Van Gelderen J, Mighell
M. Humeral shaft fractures: a review. J Shoulder Elbow Surg
2011;20:833-44. http://dx.doi.org/10.1016/j.jse.2010.11.030
73. Williams GR, Iannotti JP. Management of periprosthetic fractures: the
shoulder. J Arthroplasty 2002;17(4 Suppl 1):14-6. http://dx.doi.org/10
.1054/arth.2002.32683
74. Wright TW, Cofield RH. Humeral fractures after shoulder arthroplasty.
J Bone Joint Surg Am 1995;77:1340-6.
75. Xue Z, Ding H, Hu C, Xu H, An Z. An anatomical study of the nutrient
foramina of the human humeral diaphysis. Med Sci Monit
2016;22:1637-45. http://dx.doi.org/10.12659/msm.898361
76. Zafar MS, Porter K. Humeral shaft fractures: a review of literature.
Trauma 2016;9:273-82. http://dx.doi.org/10.1177/1460408607088315
77. Zhao JG, Wang J, Wang C, Kan SL. Intramedullary nail versus plate
fixation for humeral shaft fractures. Medicine (Baltimore) 2015;94:e599.
http://dx.doi.org/10.1097/MD.0000000000000599
78. Zlotolow DA, Catalano LW, Barron OA, Glickel SZ. Surgical exposures
of the humerus. J Am Acad Orthop Surg 2006;14:754-65.
http://dx.doi.org/10.5435/00124635-200612000-00007