Fracture of the humeral shaft is commonly due to fall and high-energy impact injury. Fracture after low-energy trauma must prompt further investigation, focusing on the possibility of malignancy or severe osteoporosis. Presence of wound, which denotes presence of open fracture, must prompt urgent attention. Nerve injury particularly of radial nerve, must be ruled out before any management is initiated [2].

Fracture of the proximal humerus often presents with swelling, pain, and bruising of the affected arm, with symptoms at its peak in the first two weeks post-injury. Due to shoulder
musculature, swelling can be more pronounced only at the anteroinferior side of the affected arm [7]. Signs of distal ischemia may be absent due to extensive collateral vasculature in the shoulder, but very severe swelling may indicate vascular injury. Large or expanding hematoma, pulsatile external bleeding, unexplained hypotension, and nerve injury should increase suspicion of vascular involvement of proximal humeral fracture [7], hence careful examination must be conducted even in the absence of peripheral ischemia. Nerve injury, most commonly in the brachial plexus and axillary nerve, must also be ruled out during assessment [7].

• Pain

  Complaints of pain and difficulty in movement of both shoulders marked the poor result. [scielo.br]

  The mean pain score for the acetaminophen subgroup was 2.1 compared with a mean pain score of 2.4 for the narcotic subgroup. This difference was not statistically significant. [ncbi.nlm.nih.gov]

  Symptoms Of Proximal Humerus Fracture Pain - Immediately following injury patient feels severe pain at rest. Pain is often intolerable following any attempt to use injured arm. Patient is unable to lie on the side of injured arm. [epainassist.com]

  Possible symptoms of a humerus fracture or upper arm fracture include: Arm pain Arm bruising Arm deformity Arm numbness Arm swelling Arm weakness Elbow pain Shoulder pain. [ebtrialattorneys.com]

• Falling

  The usual injury mechanism is a fall on an outstretched arm with the elbow extended or direct force, often causing posterior displacement or angulation. [merckmanuals.com]

  The most common cause is a fall on an outstretched hand from a standing position. Direct, intense trauma is a more frequent cause in younger patients and the injury is often more severe. [anterior-hip-surgery.com]

  Humerus fractures are common injuries most often caused by falls and motor vehicle accidents. Fracture of the humeral shaft is commonly due to fall and high-energy impact injury. [symptoma.com]

  A fall onto an outstretched arm is the typical way these fractures occur. [physioroom.com]

• Surgical Procedure

  Overview This surgical procedure repairs a break in the proximal end of the humerus. ORIF stands for Open Reduction Internal Fixation. [centralcoastortho.com]

  A biceps tenodesis is a common surgical procedure that is often carried out in conjunction with other surgical shoulder repairs to relieve biceps tendonitis. [ncbi.nlm.nih.gov]

  Surgical procedure The open reduction and internal fixation surgery involves the reduction of the fracture and securing the correctly aligned bones to allow healing. [newyorkortho.com]

• Severe Pain

  Mild to moderate pain responds to NSAIDs. Most common NSAIDs used are Motrin, Naproxen and Celebrex. Opioids - Severe to very severe pain is treated with opioids. Most common opioids used are hydrocodone and oxycodone. [epainassist.com]

  Patients with proximal humerus fracture experience severe pain, swelling, and restricted motion of the shoulder. Proximal humerus fracture is diagnosed by physical examination, X-ray of the affected area and/or computerized tomography (CT) scan. [drkellum.com]

  Back to Top Symptoms Humerus fractures cause severe pain and swelling. It may be very difficult for you to move your upper arm. If the nerves are affected, you may experience unusual sensations in the hand and weakness in your hand and wrist. [fixbones.com]

  Signs & Symptoms There is usually a history of some form of trauma (typically a fall onto an outstretched arm), accompanied by severe pain and an inability to use the affected arm. [physioroom.com]

• Ecchymosis

  Signs Swelling, Ecchymosis and pain over Shoulder Evaluate for open Fracture (rare) Evaluate affected arm for neurovascular injury Vascular injury Forearm or hand pallor (axillary artery injury) Radial pulse Sensory Exam Arm sensory changes especially [fpnotebook.com]

  Ecchymosis and edema are usually present. Perform a careful neurovascular examination. Radial nerve injury following humerus shaft fractures is relatively common. Humeral stress fractures are often missed. [emedicine.medscape.com]

  After several days, there may be intense purple bruising (ecchymosis) around the shoulder and down the arm. This is to be expected and you should not necessarily be alarmed. Significant swelling commonly occurs from the shoulder to the hand. [midwestbonejoint.com]

   Ecchymosis appears 24-48 hrs. Look for rib, scapular, cervical # in high energytrauma. Concurrent brachial plexus injury 5% Axillary nerve is susceptible in anterior #dislocation. Gentle rotation of arm & palpation of # - guide for# stability. [slideshare.net]

• Skin Discoloration

  Diagnosis of Proximal Humerus Fracture Clinical Examination- Pain over proximal humerus and shoulder joint Shoulder joint and proximal humerus deformity Joint and humerus tenderness Skin discoloration and bruises Image Studies- X-ray - X-Ray examination [epainassist.com]

• Fracture

  Fractures of the proximal humerus are common, accounting for 5% of all fractures. These fractures tend to occur in older patients who are osteoporotic. [shoulderdoc.co.uk]

  […] location: 2 fracture pattern: simple:A, wedge:B, complex:C Descriptive fracture location: proximal, middle or distal third fracture pattern: spiral, transverse, comminuted Holstein-Lewis fracture a spiral fracture of the distal one-third of the humeral [orthobullets.com]

  Proximal Humeral Fracture Repair Arthrex offers a complete proximal humeral fracture management system for all fracture classifications. The fracture systems include: percutaneous pinning, humeral SuturePlate and Univers Fracture Stem. [arthrex.com]

• Osteoporosis

  CONCLUSIONS: Multivariable regression analysis revealed that osteoporosis (less than -2.5 bone mineral density, P = 0.015), displaced varus fracture (less than 110° of NSA, P = 0.025), medial comminution (more than 1 fragment, P = 0.018), and insufficient [ncbi.nlm.nih.gov]

  Causes of Proximal Humerus Fracture Osteoporosis - Osteoporosis is observed in elderly 1 and menopausal females. Osteoporosis is a bone density disease which results in decreased bone mass and structure. [epainassist.com]

  Longer life span and osteoporosis were credited for this trend. The incidence of these fractures will continue to increase as the population base ages. [boiseshoulderclinic.net]

• Shoulder Pain

  We report a case of a 46-year-old woman who presented to the ED with left shoulder pain and swelling after a fall. [ncbi.nlm.nih.gov]

  Symptoms include arm and shoulder pain, bruising, swelling, deformity, numbness, weakness, and an inability to move the shoulder. Symptoms A humerus fracture usually produces swelling and pain in the upper arm. [anterior-hip-surgery.com]

  A third patient, a man of 71 at fracture, had complained of shoulder pain at the 1-year follow-up but was pain-free at the final evaluation. All other patients in the pain-free group had had minimally displaced fractures. [tandfonline.com]

  Possible symptoms of a humerus fracture or upper arm fracture include: Arm pain Arm bruising Arm deformity Arm numbness Arm swelling Arm weakness Elbow pain Shoulder pain. [ebtrialattorneys.com]

• Elbow Pain

  Possible symptoms of a humerus fracture or upper arm fracture include: Arm pain Arm bruising Arm deformity Arm numbness Arm swelling Arm weakness Elbow pain Shoulder pain. [ebtrialattorneys.com]

  Review Topic QID: 3219 1 Decreased risk of post-operative elbow pain 2 Decreased risk of radial nerve injury 3 Decreased risk of reoperation 4 Decreased risk of infection 5 Decreased risk of blood loss ML 2 Select Answer to see Preferred Response PREFERRED [orthobullets.com]

  Signs and symptoms of a Distal Humerus Fracture may include: Severe elbow pain at the site, where the injury occurred Signs of bruising with the elbow Stiffness or inability to move the arm, wrist, or elbow Swelling of the elbow Tenderness in the elbow [dovemed.com]

• Stiffness of the Shoulder

  It causes pain and stiffness in the shoulder. Shoulder arthroplasty may eventually be needed or may be the initial treatment of choice in the fracture management. [patient.info]

  Joint stiffness. Stiffness in the shoulder or elbow is common after a proximal humerus fracture and a distal humerus fracture respectively. You may not regain your full range of motion in these joints and they may also feel weaker. [belmarrahealth.com]

  Due to their limited movement following a proximal humerus fracture, individuals lose their range of shoulder motion and may develop stiffness of the shoulder joint. [moveforwardpt.com]

• Seizure

   Severe soft tissue disruption always requiresurgical intervention Seizures & electric shock – indirect causes. 3.  Articular head, G.T, L.T, for insertion for rotatorcuff & shaft. Metaphyseal flare – surgical neck  mostcommon site of # Anatomic [slideshare.net]

  Because epilepsy and use of seizure medication were highly correlated, only seizure medication use was included in the multivariate model. [aje.oxfordjournals.org]

  However, patients may present following a seizure, electrical shock or following direct trauma. Proximal humeral fractures usually result from a fall on an outstretched arm. [radiopaedia.org]

• Dizziness

  Side effects resulting from the use of seizure medication include nausea, dizziness, and sleepiness, all of which could lead to falls. In addition, osteomalacia has been associated with seizure medications ( 28 ). [aje.oxfordjournals.org]

  Side effects resulting from the use of seizure medication include nausea, dizziness, and sleepiness, all of which could lead to falls. In addition, osteomalacia has been associated with seizure medications (28). [academic.oup.com]

For the humeral shaft fracture, two radiographs 90 degrees to each other (anteroposterior and lateral) and including the shoulder and elbow joints must be taken [2]. Same radiographs must be used also in distal humeral fractures, although splints and plasters may obstruct the view, hence warranting gentle traction prior to taking the radiographs [5]. Standard trauma series radiographs for suspecting proximal humerus fracture consist of anteroposterior, lateral, and axillary views. Axillary view may be uncomfortable for patient since the arm needs to be removed from the sling while taking the radiograph, hence Velpeau or modified axillary view can be alternatives. Glenoid, coracoid, and acromion may block the view of fracture in anteroposterior view taken in standard anatomic planes. Better view can be obtained by taking the radiograph on the glenoid plane by tilting
the X-ray beam 30 degrees medial to the normal plane [7].

CT scan, especially those with three-dimensional imaging, is increasingly used to further assess the complex anatomy of proximal humerus fracture and articular surface injury which is impossible to see in conventional radiographs [7]. It is also used to assess vascular injury in humeral shaft fracture, along with angiogram. However, it is not usually done in assessing distal fractures, except in cases wherein a less invasive approach for open reduction and internal fixation is contemplated, or in elderly patients to whom an ORIF or direct arthroplasty management is decided.

MRI is not frequently used in assessing fracture since it is inferior to CT in providing details on bone architecture [7]. In low resource setting, ultrasound can be used as an alternative to CT scan. Advanced ultrasound is now used also to rule out lacerated or entrapped radial nerve in humeral shaft fracture [8].

Humeral shaft fracture

Humeral shaft fracture is usually managed nonoperatively. The wide range of motion of the shoulder which easily accommodates angulatory, axial, and rotational malunion, as well as minimizing the functional limitation, makes nonoperative management enough for humeral shaft fracture, despite not achieving anatomic reduction. The shaft also does not bear weight, enveloped with a number of muscles, has rich supply of blood, and easily splinted. Functional bracing, presently a prefrabricated device with plastic support remains the gold standard in treating humeral shaft fracture and has a high rate of union. Initial deformities are corrected by gravity, time, and brace [2].

Indications for surgical management of humeral shaft fracture can be divided into three groups: fracture indication, associated injuries, and patient indications. Fracture indications include shortening of the arm of more than 3 cm., rotation of greater than 30 degrees, angulation of greater than 20 degrees, segmental fracture, pathologic primary cause, and shoulder or elbow joint involvement. Associated injuries such as open wound, vascular or brachial plexus injury, ipsilateral forearm, elbow, or shoulder fractures, bilateral humeral fractures, burn, and high velocity gun-shot injury also warrants operative management. Patient factors include multiple injuries, Glasgow Coma Scale greater than 8, chest trauma, poor tolerance, and morbid obesity are also indications [2].

Plate osteosynthesis is the gold standard in fixation of humeral shaft fractures, especially those with proximal and distal extension and those with open fractures. Most commonly used plate is a broad, 4.5mm, limited-contact dynamic compression plate. Bridge plating technique is required in comminuted fracture. For patients with poor bone quality, longer plate is required to improve stability. For plate fixation, two approaches are generally used: the anterolateral (or brachialis-splitting) approach for fractures in the middle or proximal third of the shaft, and the posterior (triceps-splitting or modified posterior) approach for fractures in the midshaft or distal third of the humeral shaft [2].

Fracture of proximal humerus

Most of the fracture of the proximal humerus can be treated nonoperatively also [9]. The range of motion of the shoulder joint accommodates the moderate angular deformity without significant functional loss. 45 degrees of angulation and less than 1 cm of displacement is an acceptable deformity, but these criteria are not absolute since it still depends on the acceptability for the patient.

Fracture displacement, as an indicator of stability, is an indication for surgical management. The goal is to restore the injured proximal humerus anatomy by stable fixation to gain functional movement as early as possible [8]. For 1 cm of displacement between the head and shaft fragment, or 5 mm of displacement of tuberosity fragment, transosseous suture fixation is used [9] in which a non-absorbable suture is used to capture rotator cuff tissue anteriorly, laterally, and posteriorly to the fragment. For cases with high risk of osteonecrosis requiring less exposure of the bones, close reduction by percutaneous fixation can be done. A difficult procedure, it is done by inserting terminally threaded Schantz
pins and bicortical pins from the greater tuberosity to the medial humeral shaft. This option however requires compliance of the patient. For better preservation of tissues, intramedullary nailing can be done [8].

Open reduction and internal fixation by locked plates is more preferred than using conventional plates due to difficulty in securing the screws due to poor bone quality in the region. It is indicated in fractures with metaphyseal comminution [9]. For fractures with more than 40% articular involvement, hemiarthoplasty is indicated [9]. This is also a difficult procedure, and the presence of infection is a contraindication for this option [9].

Fracture of distal humerus

Nonoperative management is reserved to patients with undisplaced fracture, inability to tolerate anesthesia, and dementia [10]. Pain control is challenging especially on the first week postsurgery, and most of the time requires hospitalization [11]. Satisfactory outcome can be achieved if the three complications – nonunion, symptomatic malunion and osteonecrosis – are avoided [11].

However, operative management is still preferred generaly to fractures of distal humerus due to high rate of nonunion in the nonoperative management [10]. Operative treatment goal is to restore the joint surface with internal fixation that allows early motion [8]. There are lots of approaches in operative management of distal humerus fracture. Regardless of the management employed, the ulnar nerve must be isolated, mobilized and protected throughout the procedure [10]. Posterior approach with olecranon osteotomy was formerly used frequently [8] since it provides better visualization of the articular surface [10], but there are concerns on healing and symptomatic implants [8]. More commonly used nowadays are the tricepsreflecting, triceps-reflecting anconeus pedicle, and triceps-splitting approaches which has fewer complications [8]. Using plate fixation resulted to better surgical outcomes in the past few years. The principle for this option is anatomic articular reduction and rigid fixation by two plates [10]. Orientation or postion of the plates, whether parallel or perpendicular, is still debatable. Some studies show nonunion in perpendicular plate fixation, while other studies show no significant difference between the two in terms of outcome [10]. Locking plates can also be used with excellent result, but the plates are usually expensive, and the indications for its use are still unclear [10].

The radial head and the coronoid process are important stabilizers of the elbow, hence salvaging them should be done if possible [8]. Injury to brachial artery, although rare, should be ruled out as early as possible, and if present, it should be reconstructed immediately using a saphenous vein graft. Compartment syndrome is also a complication post-surgery, hence patients should be closely monitored for swelling on the surgical site. Injury of median, ulnar, or anterior interosseous nerves results to simple neuropraxia most of the time, but further investigation, specifically exploration, must be done if normal function does not return after 3 months post-injury [8].

Due to the surrounding musculature and soft tissue, the prognosis of humeral shaft fracture is better compared to the injury in the distal part. Most of the humeral shaft fracture can be managed nonoperatively [2]. It is actually the easiest to manage among the fractures of the long bones.

Functional bracing, the “gold standard” in nonoperative management of facture of humeral shaft, reportedly has 96% to 100% union rate. In addition, the range of motion of the elbows and shoulder, and the tolerance to small shortening of the humerus makes the humeral shaft fracture tolerable and only cause minimal functional deficit [8]. Usual nerve injury is radial nerve neuropraxia, and is bruised or stretched only most of the time, hence function can be expected to return to normal [8].

Distal fracture, which often involves comminution of involved bones, on the other hand often results to abnormal elbow, though improvement has been seen recently due to improved technology in the management such as implant technology, surgical approaches, and rehabilitation protocols. Joint function is always compromised due to pain, stiffness, and weakness. Unlike the fracture of humeral shaft, it is often managed operatively [8].

In the US, regardless of the anatomic site, the most common cause of fracture of the humerus in the adults especially in the elderly people is fall [1], which accounts for 88% of all cases in emergency department setting. This is followed by motor vehicle accidents, the more common cause of fracture in the younger adults, at 8%, and impact injury at 5% [1]. In children, fractures are often due to environmental causes and hence preventable. For instance, playing with the monkey bars is the most common cause of supracondylar fracture among pediatric patients less than 15 years old [1].

The type of fracture also reflects the mechanism of injury. For example, rotational injuries such as forceful wrenching of arms behind the back may cause spiral fracture. Most of the fractures of proximal humerus are usually physeal. In children, severe fracture usually gives suspicion of physical abuse [2].

Fracture of the humerus which occurred at minimal trauma should raise a flag on possible primary cause such as severe osteoporosis and malignancy, whether metastasis or a primary one like myeloma, warranting more in-depth history taking [2].

Risk factors for having fracture of the humerus are low bone density, history of fracture, inactive lifestyle, and low body mass index, history of fall, frequent walking, poor vision and diabetes mellitus [3]. It was also found that depression, left-handedness, epilepsy, seizure medication use, and use of hearing aids increases the chances of having proximal humerus fracture [4]. Women and the elderly are also at higher risk of having fracture of the arm, as well as the Caucasians compared to the Blacks [4].

Fracture of the humeral shaft is relatively common. The incidence is at 3 to 5% of the total cases of fracture [1]. In the US, humeral fracture has an annual incidence rate of 122 per 100,000 people, less than the reported rate in other developing countries such as Japan and Europe [1]. The most common site is the proximal part, accounting for 50% of the total cases of humerus fracture. Fracture of the distal humerus is rare and commonly occurs in children [1]. Fractures involving two sites of the humerus occur only at less than 1% of the time [1].

There is a bimodal age distribution on the incidence of humeral shaft fracture, with a peak at age bracket 21-30 years old, mostly male, and at age 60-80 years old, mostly female. Peak in the younger age group is usually attributed to high-impact trauma [2], while in the second but larger peak, the most common cause is simple fall [2]. Larger number of proximal humerus fracture is also seen at age bracket 45-64 years old, and the number of emergency consults with proximal humerus fracture increased continuously at age 84.

Most of the cases are either due to a high-energy impact injury or low-energy falls, specifically in a forward direction [6]. Fracture of the humeral shaft usually occurs distal to the
surgical neck of the proximal humerus and proximal to the supracondylar ridge distally, considered to be the main fracture line [2]. Distal fracture is usually multifragmented, occurring in the osteopenic bone. In 70% of the time, distal fracture occurs after falling on their elbows after failing to outstretch the arms [5]. Fracture of the proximal humerus, on the other hand, is caused by combination of external force and forces generated by the intrinsic shoulder musculature [7]. During an impact injury, the humeral head is fractured by the glenoid which acts as an anvil in the shoulder [7].

There are no guidelines for the prevention of humerus fracture.

Fracture of the humerus is usually caused by trauma, most commonly by direct fall in the arm or shoulder in the elderly, and vehicular accidents in the younger adults. X-ray is still the primary diagnostic tool used to assess the fracture, although CT scan is gaining more attention in the past few years.

Due to difference in the composition of bone and in the surrounding anatomy, severity and management of humeral fracture depends on the site of injury. Fracture of the shaft is usually managed nonoperatively with high success rate, but fracture of proximal or distal humerus is managed operatively most of the time.

Fracture of the humerus (upper arm bone) is usually caused by falls, although a high number of cases in younger adults are caused by vehicular accidents. Swelling on the affected area is the usual symptom, but involvement of blood vessels and nerves must also be ruled out especially in the fracture of the arm near the shoulder and elbow. X-ray remains the primary choice of imaging modality used in diagnosis, although CT scan is increasingly preferred by orthopedic surgeons.

Management is dependent on the site of fracture. Fracture of the shaft can be managed without surgery with minimal and tolerable effect. Fracture of the arm near the shoulder or elbow is preferably managed through surgery, depending on the severity of the injury.

1. Kim SH, Szabo RM, Marder RA. Epidemiology of humerus fractures in the United States: Nationwide emergency department sample, 2008. Arthritis Care Res. 2012; 64-3: 407-414.
2. McKee MD, Larsson S. Humeral Shaft Fractures. In: Bucholz RW, Court-Brown CM, Heckman JD, Tornetta P, ed. Rockwood and Green's Fractures in Adults, Philadelphia: Lippincott Williams & Wilkins; 2010.
3. Kelsey JL, Browner WS, Seeley DG, Nevitt MC, Cummings SR. Risk factors for fractures of the distal forearm and proximal humerus. The study of osteoporotic fractures research group. Am J Epidemiol. 1992; 135(5): 477-89.
4. Chu SP, Kelsey JL, Keegan THM, et al. Risk Factors for Proximal Humerus Fracture. Am J Epidemiol. 2004; 160: 360-367. 
5. Athwal, GS. Distal Humerus Fractures. In: Bucholz RW, Court-Brown CM, Heckman JD, Tornetta P, ed. Rockwood and Green's Fractures in Adults, Philadelphia: Lippincott Williams & Wilkins; 2010.
6. Palvanen M, Kannus P, Parkkari J, et al. The injury mechanisms of osteoporotic upper extremity fractures among older adults: a controlled study of 287 consecutive patients and their 108 controls. Osteoporos Int 2000; 11(10): 822-831.
7. Robinson CM. Proximal Humerus Fractures. In: Bucholz RW, Court-Brown CM, Heckman JD, Tornetta P, ed. Rockwood and Green's Fractures in Adults, Philadelphia: Lippincott Williams & Wilkins; 2010.8.
8. Crenshaw AH, Perez, EA. Fractures of the Shoulder, Arm, and Forearm. In: Canale ST, Beaty JH, ed. Campbell's Operative Orthopaedics, Philadelphia: Mosby Elsevier; 2007
9. Nho SJ, Brophy RH, Barker JU, Cornell CN, MacGillivray JD. Management of Proximal Humeral Fractures Based on Current Literature. J Bone Joint Surg Am. 2007; 89: 44-58.
10. Nauth, A, Mckee MD, Ristevski B, Hall J, Schemitsch EH. Distal Humeral Fractures in Adults. J Bone Joint Surg Am. 2011; 93 (7): 686-700. 
11. Murray IR, Amin AK, White TO, Robinson CM. Proximal humeral fractures: Current concepts in classification, treatment and outcomes. J Bone Joint Surg. 2011; 93-B: 1-11.