Fractures of the humeral shaft are commonly caused by falls onto the hand or elbow. While most can be treated non-operatively, operative treatment may be necessary to restore alignment and stability through plate osteosynthesis, intramedullary nailing, or external fixation. Nerve injuries, particularly to the radial nerve, are a common complication and usually recover spontaneously, though exploration may be needed if function does not return within 12 weeks. Conservative treatment involves immobilization in a hanging cast with early range of motion exercises to prevent stiffness.

1. Fracture Shaft of Humerus
Dr. Ashiqur Rahman
Resident Orthopedics
Dhaka Medical college Hospital

2. Epidemiology:
- 3% of all fractures;
- Most can be treated non- operatively
Mechanism of injury:
- Spiral fracture: A fall on the hand may twist the humerus.
- Oblique or transverse fracture: A fall on the elbow with the
arm abducted exerts a bending force.
- A direct blow to the arm causes a fracture which is either
transverse or comminuted.
- Fracture of the shaft in an elderly patient may be due to a
metastasis.

4. Pathological anatomy:
 With # above the deltoid insertion, the proximal fragment is
adducted by pectoralis major.
 With # lower down, the proximal fragment is abducted by deltoid.
 Injury to the radial nerve is common, though fortunately recovery is
usual.

5. Clinical features:
 The arm is painful, bruised and swollen.
 It is important to test for radial nerve function before and after
treatment.
 This is best done by assessing active extension of the
metacarpophalangeal joints; active extension of the wrist can be
misleading because extensor carpi radialis longus is sometimes
supplied by a branch arising proximal to the injury.

6. Conservative treatment:
- A ‘hanging cast’ is applied from shoulder to wrist with the
elbow flexed 90 degrees.
- The forearm section is suspended by a sling around the
patient’s neck.
- This cast may be replaced after 2–3 weeks by a short (shoulder
to elbow) cast or a functional polypropylene brace which is
worn for a further 6 weeks.
- The wrist and fingers are exercised from the start.

7. - Pendulum exercises of the shoulder are begun within a week.
- Active abduction is postponed until the fracture has united
(about 6 weeks for spiral fractures but often twice as long for
other types).
- Once united, only a sling is needed until the fracture is
consolidated.

8. ****Patients often find the hanging cast uncomfortable, tedious
and frustrating.
-they can feel the fragments moving and that is sometimes quite
distressing.
-The temptation is to ‘do something’, and the ‘something’
usually means an operation.

9. It is as well to remember:
(i) That complication rate after internal fixation of humerus is
high.
(ii) That great majority of humeral # unite with non-operative
treatment and
(iii) There is no good evidence that union rate is higher with
fixation(and the rate may be lower if there is distraction with
nailing or periostel stripping with plating).
(iv) There are nevertheless, some well-defined indications for
surgery.

11. The goal of operative treatment:
- Reestablish length, alignment, and rotation
- Stable fixation that allows early motion and ideally
- Early weight bearing on the fractured extremity.
Options for fixation:
1. Plate osteosynthesis (“gold standard”)
2. Intramedullary nailing, and
3. External fixation.

14. - In 1963, Holstein and Lewis associated a special type of
fracture of the distal humerus, a simple displaced spiral
fracture, with the distal end deviating toward the radial side,
with an increased rate of radial nerve palsy.
-They reported a high incidence of entrapment of the nerve
within this type of fracture and recommended radial nerve
exploration in the presence of clinical symptoms.

15. - Subsequent studies confirmed an increased risk of radial nerve
injury with this type of fracture but supported the expectant
policy even in the presence of clinical symptoms.
- As their findings indicated that the radial nerve usually recovers
regardless of the pattern and location of the humeral shaft
fracture.

16. - Heckler and Bamberger114 surveyed practice tendencies in
USA by sending a questionnaire to 2,650 physicians regarding
their practice in cases of humeral shaft fracture associated with
radial nerve palsy.
- From 558 responses, the authors concluded that most
physicians agreed that:
…The incidence of recovery is high and observation is
justified.

17. IF of Holstein Lewis fracture

22. Anatomy of arm
 Arm is well enveloped with muscles and soft tissues. So prognosis is good.
 Medial and lateral intermuscular septa are tough fibrous band that divide
the arm in anterior and posterior compartment.
- Anterior compartment has three muscles:
o Biceps brachii,
o Brachialis,
o Coracobrachialis
- Posterior compartment:
o Triceps Brachii
 Anterior compartment muscles BBC is supplied by musculocutaenious
branch and arterial supply by branches of brachial artery.

23. Approaches:
-Anterolateral approach (brachialis-splitting approach)
- A posterior approach (triceps splitting or modified posterior
approach)

25. Antero-lateral approach to the shaft of the Humerus
(Thompson;Henry)
- Incise the skin in line with the anterior border of the deltoid
muscle from a point midway between its origin and insertion,
distally to the level of its insertion, and proceed in line with the
lateral border of the biceps muscle to within 7.5 cm of the
elbow joint.
- Divide the superficial and deep fasciae, and ligate the cephalic
vein.
- In the proximal part of the wound, retract the deltoid laterally
and the biceps medially to expose the shaft of the humerus.

26. - Distal to the insertion of the deltoid, expose the brachialis
muscle, split it longitudinally to the bone, and retract it sub-
periosteally, the lateral half to the lateral side and the medial
half to the medial.
-Retraction is easier when the tendon of the brachialis is relaxed
by flexing the elbow to a right angle. The lateral half of the
brachialis muscle protects the radial nerve as it winds around
the humeral shaft.

27. Modified posterior approach(Triceps-Reflecting)

29. Complications of Shaft Humerus #
Early:
1. Vascular injury: Any injury to brachial artery
2. Nerve injury:
a. Nerve injury Radial nerve palsy (wrist drop and paralysis of
the metacarpophalangeal extensors) may occur with shaft
fractures. The commonest associated injury to a closed
diaphyseal humeral fracture is the injury of the radial nerve
(10% to 12% of all closed humeral shaft fractures.
b. Particularly oblique fractures at the junction of the middle
and distal thirds of the bone (Holstein–Lewis fracture).

30. c. If nerve function was intact before manipulation but is
defective afterwards, it must be assumed that the nerve has
been snagged and surgical exploration is necessary.
d. Otherwise, in closed injuries the nerve is very seldom divided,
so there is no hurry to operate as it will usually recover.
e. The wrist and hand must be regularly moved through a full
passive range of movement to preserve joint motion until the
nerve recovers.

31. f. If there is no sign of recovery by 12 weeks, the nerve should be
explored.
g. It may just need a neurolysis, but if there is loss of continuity
of normal-looking nerve then a graft is needed.
h. The results are often satisfactory but, if necessary, function
can be largely restored by tendon transfers
 Median and ulnar nerve can be injured in 1.3 % and 2.4%
respectively.

32. Late:
1. Delayed and non-union
2. Joint stiffness