B9. Proximal and middle shaft humeral fractures.

Most humeral shaft fractures occur on the proximal end. It’s more common in elderly women usually due to fall on outstretched arm on the basis of osteoporosis. It’s classified according to the NEER classification. Axillary nerve injury may occur. Treatment is mostly conservative with a sling.

Midshaft humeral fractures may occur in young or elderly, mostly in young. These are less common than proximal fractures. Radial nerve injury may occur, especially if the distal third is involved. Treatment is mostly conservative with a hanging cast/sling.

Fractures of the distal humerus are considered elbow fractures.

Etiology

Fall onto outstretched arm (elderly) or high energy trauma (young).

Classification

Proximal humeral fractures are classified according to the NEER classification, according to which part of the proximal humerus is involved and the number of displaced segments.

Clinical features

Patient holds the arm close to the chest with the healthy arm. Pain and crepitus may be detected on palpation. There may be decreased lateral deltoid sensation and deltoid function due to axillary nerve injury in proximal fractures, while signs of radial nerve injury is seen in midshaft fractures.

Diagnosis and evaluation

X-ray is usually sufficient, but CT may be necessary for dislocation or multifragmented fractures. Traction x-ray may be indicated in case of displacement or comminution. MRI is indicated in suspected rotator cuff injury.

Treatment

Proximal fractures

Conservative in case of minimally displaced fractures. It involves a sling and physical therapy. Operative in case of open, displaced, multifragmented, or anatomical neck fractures, or if there is neurovascular injury. It involves screws, K-wires, tension band, plate, hemiarthroplasty, or delta prosthesis.

Midshaft fractures

Conservative in most cases, with reduction followed by a hanging cast/splint. Surgery may be necessary in case of neurovascular injury, failed reduction, nonunion, or open, segmental, or transverse fractures.