INTRODUCERE

Fracturile humerusului pot apărea proximal, la nivelul axului (diafizar) sau distal. Majoritatea

fracturilor de humerus proximal și de ax mediu sunt nedispuse și pot fi tratate conservator

(nechirurgical).

CLINICAL ANATOMY The humerus is the largest bone in the upper

extremity. The proximal humerus articulates with the glenoid of the scapula to form the
shoulder joint (figure 1). The muscles and tendons of the rotator cuff, the acromion, and
ligamentous attachments such as those between the coracoid process of the scapula
and the acromion, serve to both stabilize the glenohumeral articulation and provide for a
wide range of motion of the shoulder joint. The distal humerus articulates with the radius
and ulna at the elbow.
The greater tuberosity, located lateral to the humeral head and on the superior aspect of
the humerus, provides the attachment for three of the rotator cuff muscles:
supraspinatus, infraspinatus and teres minor (figure 2). The lesser tuberosity of the
humerus is located on the anterior surface of the humerus and provides the attachment
for the subscapularis muscle. For the purposes of fracture classification, the lesser
tuberosity marks the boundary between the proximal humerus and the midshaft.

The humeral shaft supplies the attachment for a number of powerful muscles. The
pectoralis major muscle inserts on the proximal shaft while the deltoid muscle attaches
to the midshaft. The biceps brachii and triceps muscle groups attach further distally.

The tendon of the long head of the biceps brachii muscle passes between the lesser
and greater tuberosities as it courses from its origin on the superior portion of the
glenoid to its insertion on the radius.

The blood supply to the humeral shaft is supplied by the axillary and brachial artery, the
latter branches to form the radial and ulnar artery (figure 3 and figure 4 and figure 5).
The vascular supply can be disrupted if there is considerable displacement of shaft
fragments.
Innervation of the muscles in the posterior compartment of the arm and forearm is
provided by the radial nerve. The radial nerve enters the arm medial to the humerus and
anterior to the long (medial) head of the triceps muscle and travels inferolaterally,
moving around and adjacent to the humeral shaft, in the radial groove. Thus, the radial
nerve is susceptible to injury when there is significant displacement of mid to distal
humeral shaft fractures [1]. Median and ulnar nerve injuries are uncommon with such
fractures [2].
 EPIDEMIOLOGY AND RISK FACTORS Midshaft humeral fractures

account for about 2 percent of all fractures [3]. They occur in all age groups, but show a bimodal

distribution: The first peak is seen in the third decade in males and is often associated with high

velocity trauma; the second peak is noted in females in the seventh decade and is associated

with low velocity falls [1]. An observational study of 401 humeral shaft fractures noted that 68

percent resulted from a simple fall and 90 percent overall were due to trauma [1]. Trauma,

increasing age, and osteoporosis are known risk factors. (See "Falls in older persons: Risk

factors and patient evaluation" and "Falls: Prevention in community-dwelling older persons".)

MECHANISM OF INJURY Midshaft fractures typically result from trauma such

as a direct blow or bending force to the humerus and, less commonly, from a fall on an

outstretched hand or elbow. Midshaft fractures may also result from strong muscle contractions

such as in high-velocity throwing or arm wrestling. There is some debate whether this occurs

solely from a violent muscle contraction or requires an underlying stress fracture associated with

the muscle contraction. A study of 90 recreational baseball players with midshaft humeral

fractures concluded that these fractures are caused by the accelerated phase of throwing, and

can occur in any recreational baseball player who tries to make a hard throw [4].

SYMPTOMS AND EXAMINATION FINDINGS Patients with midshaft

humeral fractures typically present with severe arm pain in the area of the mid-arm but
may have referred pain to the shoulder or elbow. Swelling and ecchymosis is often
apparent shortly after the injury. The presence of abrasions or lacerations should be
noted. If medicolegal circumstances warrant and the patient agrees, photographs of the
injured arm can be obtained.

There is significant tenderness to palpation and crepitus may be noted at the fracture
site. Shortening of the upper arm suggests the presence of significant humeral shaft
displacement. Careful examination, including inspection and palpation of the shoulder
and elbow, are important to assess for other injuries.

The initial evaluation of midshaft humerus fractures includes a detailed neurovascular

exam of the affected arm, including careful assessment of the radial and ulnar arteries
and the function of the radial, median, and ulnar nerves.

The radial nerve is the nerve most commonly injured by midshaft humerus fractures.
Injury to the radial nerve results in weakness of wrist, finger, and thumb extension and
some weakness of elbow supination. Motor function can be tested by giving the “thumbs
up” sign (picture 1) and testing resisted extension of the thumb (picture 2). Sensory loss
may be present on the dorsum of the hand and is easily tested at the dorsal web space
between the thumb and index finger.
Injury to the median nerve is uncommon following midshaft humeral fractures, but, when
it occurs, results in weakness of the flexor muscles of the hand and loss sensation on
the palmar surface of the thumb and the index and middle fingers. The largest branch
and most commonly injured portion of the median nerve is the anterior interosseus
nerve. It lacks a sensory component and results in loss of hand and finger flexion. This
is best evaluated by having the patient give an “OK sign,” which tests the flexor pollicis
longus (thumb flexion) and flexor digitorum profundus (DIP flexion of the index finger)
(picture 3). Anterior interosseus syndrome results in weakness or flattening of the “OK
sign” due to loss of thumb and index finger flexion (picture 4).  
The ulnar nerve is seldom injured by midshaft humeral fractures. Injury to the ulnar
nerve results in dysfunction of the dorsal and palmar interossei and an inability to
abduct and adduct the fingers. This can be tested by asking the patient to make the
“peace sign” (picture 5) and testing the strength of the interossei (picture 6).

DIAGNOSTIC IMAGING Radiographs of the humeral shaft in an

anteroposterior and lateral plane are necessary to evaluate the amount of angulation or
displacement of the fracture. If physical examination cannot exclude injury to the
shoulder and elbow, radiographs should include those joints as well.
Fracture patterns — Fractures of the humeral shaft can be spiral, oblique, or
transverse. The AO North American classification system sorts each fracture in to three
lettered categories (figure 6):
●A - Simple fractures (image 1)
●B - Wedge fractures
●C - Complex (comminuted) fractures

Depending on the location of the fracture, displacement of the proximal and distal
fragments can occur.

●Fractures near the midpoint of the humeral shaft typically assume an apex lateral
position. The proximal fragment is pulled laterally by the deltoid, while the distal
 fragment is pulled medially by the triceps and biceps. Fractures near the midpoint
of the shaft are more likely than more proximal or distal fractures to shorten due to
the strong pull of the biceps and triceps muscles.
●Shaft fractures that are located more proximally are angulated apex medially due
to the medial pull of the pectoralis major muscle proximally and the lateral pull of
the deltoid muscle distally.

ORTHOPEDIC CONSULTATION OR REFERRAL

Indications for surgical referral — Based on available evidence and broad clinical

experience, approximately 70 to 80 percent of humeral shaft fractures can be treated
non-surgically, but some require functional bracing or use of traction for adequate
treatment [5]. Physicians without experience using hanging casts and functional braces
should refer patients with humeral shaft fractures for orthopedic consultation and
management.
Acceptable positioning for a midshaft humerus fracture includes [6-8]:
●Less than 20 degrees of anterior or posterior angulation
●Less than 30 degrees of varus angulation
●Less than 3 cm of shortening
●Less than 15 degrees of rotational deformity
Varus angulation of up to 10 degrees is common [9]. Fractures that exceed the limits of
acceptable alignment should be referred for closed reduction or operative stabilization.

Immediate surgical referral is required for a midshaft humerus fracture associated with
vascular injury and for open fractures. Other absolute indications for referral include:

●Fracture associated with articular injuries

●Brachial plexus injuries
●Ipsilateral forearm fractures (eg, floating elbow)
●Bilateral humerus fractures
●Pathologic fractures (eg, associated with bone tumor)
●Concomitant traumatic major non-humeral fractures (eg femur fracture)
●High-velocity gunshot injuries (depending on the extent of injury, may require
immediate surgical consultation)
●Fracture associated with severe soft tissue injuries or significant skin involvement
[10]
Displaced distal spiral shaft fractures (Holstein Lewis fractures) have a high association
with radial nerve injury and are generally best referred for surgical evaluation, and
possible exploration and repair [11].
We suggest referral for all humeral shaft fractures associated with radial nerve injuries
at presentation. However, it remains uncertain whether operative intervention is
necessary in all cases of radial nerve dysfunction following fracture manipulation.
Approximately 75 to 90 percent of radial nerve injuries at presentation are neurapraxias
that resolve without intervention [11].

Other relative indications for referral include:

 ●Transverse fractures that are relatively unstable and at a high risk of shortening
●Patient noncompliance
●An obese body habitus that may result in increased varus deformity
Surgery versus bracing — Multiple systematic reviews have found no evidence from
high quality trials to determine whether surgery or bracing is the best management for
humeral shaft fractures [12-14]. Subsequent randomized trials and observational
studies described below suggest better outcomes for surgical management, but the
results are not definitive:
●A randomized trial comparing open reduction and internal fixation (ORIF) using
compression plating (n = 38) with functional bracing (n = 44) for closed, displaced
humeral shaft fractures reported no significant differences in functional outcome, as
determined by Disabilities of the Arm, Shoulder, and Hand (DASH) scores (a
validated score assessing symptoms and function) [15]. However, 13 patients
originally assigned to functional bracing required surgical treatment by 12 months,
11 for nonunion. Few other complications occurred.
●A randomized trial comparing minimally invasive bridge plating through an anterior
incision with functional bracing in 110 patients reported a nonunion rate of 0
percent for the surgical group versus 15 percent for the bracing group [16]. The
surgery group had statistically superior DASH scores at six months but not at one
year.
●A randomized trial involving 60 patients comparing ORIF compression plating with
functional bracing reported a shorter time to union in those treated with ORIF (13.9
versus 18.7 weeks) [17]. Differences in DASH scores and nonunion rates were not
statistically significant.
●A retrospective study comparing results in 213 patients with a midshaft humerus
fracture reported an 8.7 percent nonunion rate in those treated with a compression
plate versus a 20.6 percent nonunion rate in those treated with bracing, while
malunion rates were 1.3 versus 12.7 percent, respectively [13]. There were no
differences in time to union, infection rates, or final range of motion. Radial nerve
palsy was observed in 9.5 percent of the nonoperative group versus 2.7 percent of
the surgical group, but all resolved. A subsequent retrospective study of 186
patients reported similar delayed union rates (19 percent) and similar rates of radial
nerve injury (9 to 10 percent) in the operative and non-operative treatment group,
although 5 percent of the radial nerve injuries occurred as a direct result of
operative fixation [18].

INITIAL TREATMENT Most humeral shaft fractures can be treated initially in

a coaptation splint. Some spiral, oblique and comminuted fractures require traction, in
addition to splinting, to achieve appropriate alignment.
Transverse fractures — Transverse fractures do not require traction and can be
treated initially with a splint and standard sling. Initial splinting of humeral shaft fractures
is commonly done with a coaptation (sugar tong) splint (figure 7). The splint is applied to
the medial aspect of the upper arm in the upper portion of the axilla and extended down
around the elbow, up past the deltoid to the top of the shoulder. Slight valgus molding of
the splint can decrease varus malalignment. Ensuring the splint extends deep into the
axilla, proximal to the fracture sight also helps to minimize varus angulation. (See "Basic
techniques for splinting of musculoskeletal injuries", section on 'Sugar tong splints'.)
Spiral, oblique, and comminuted fractures — Some spiral, oblique, and comminuted
fractures require a degree of traction to achieve adequate positioning. This can be
accomplished by using a coaptation (sugar-tong) splint with a collar and cuff sling, or a
hanging cast. Initial immobilization with a splint and collar and cuff sling is preferred to
casting if there is substantial swelling present. Use of a hanging cast is appropriate for
reducing apex medial, lateral, anterior, or posterior angulation, if there is minimal
swelling and the patient can be relied upon to watch for symptoms and signs of
constriction by the cast or the appearance of compartment syndrome. If appropriate
alignment cannot be accomplished with these techniques, surgical referral is needed.
Sugar tong splint with collar and cuff sling — The weight of the arm and the plaster
coaptation (proximal sugar tong) splint (figure 7) provide gentle traction when the elbow
is unsupported and the cuff is placed at the wrist or distal forearm (figure 8).
Hanging cast — Application of a hanging cast (figure 9) is similar to that for a long arm
cast. The elbow is placed in 90 degrees of flexion and the forearm in a neutral position.
The proximal portion of the cast extends 2 cm above the fracture site. The cast should
be hung from the neck to the distal forearm with the elbow left unsupported at all times
(this requires sleeping sitting upright). The weight of the cast is to be no more than two
pounds, which is equivalent to one made from three 4 inch (10 cm) wide and one 3 inch
(7.5 cm) rolls of plaster [19].

Adjustments to the length of the neck strap and the distal attachment points can be
made to adjust for angulation. In order for the hanging cast to provide traction or to
provide a force to reduce fracture angulation, the cast must be unsupported except at
the attachment point and the patient must be upright at all times. This means sleeping in
an upright position.