Humeral Shaft Fracture

Mechanism

Usually a direct blow
May occur from a fall on an outstretched arm in the elderly

Timing of injury
Other locations of pain
Numbness or tingling

Radial nerve palsy common with this type of injury

Other fragility fracture (hip fx, compression fx of spine, proximal humerus fracture)
Hand dominance
Profession

Possible implications on management

Vitals

Remove wrapping or sling from about the shoulder/arm to assess the skin
Assess for deformity, bruising, edema
Soft tissue defect/poke hole that probes to fracture = open fracture

Small poke hole wounds near the fracture site with a slow, continuous ooze is indicative of an open fracture

Do not miss this and confirm antibiotics were given
Do not forget to look in the axilla

Examine the forearm compartments (soft and compressible, firm but compressible, etc.)
Palpate the hand, wrist, elbow, arm and shoulder to identify concomitant injuries
Palpate the compartments of the upper arm

Compartment syndrome less common with humerus fractures but it is good to get a baseline assessment of the swelling

Motor Exam:

Axillary nerve

Difficult to assess because abduction will cause pain in this setting

Backup: push elbow back into the bed/gurney

Median Nerve/ Anterior interosseous nerve (AIN)

Opposition of the thumb

Opponens innervated by the median nerve - helpful to assess if concern for acute carpal tunnel syndrome

Flexion of wrist, fingers, thumb
“A-OK sign” = AIN

Tests flexion of thumb IP joint (FPL) and flexion of index DIP joint (FDP)

Radial nerve/ Posterior interosseous nerve (PIN)

Radial nerve palsy is commonly seen in humeral shaft fractures especially midshaft and distal third
Extension of wrist, fingers, thumb

Radial nerve palsy is common seen in humeral shaft fractures especially midshaft and distal third

“Thumbs up” = PIN

Tests extension of thumb IP and MCP joints (EPL))

Palm on flat surface and lifting/extending thumb off the surface is also a good test for PIN (tests extension of thumb MCP joint (EPL))

Ulnar nerve

Finger abduction (spread fingers, “peace sign”), finger adduction, cross fingers (“promise”)

Sensory Exam:

Median, Radial, Ulnar nerve distributions

Radial: Dorsal first web space
Median: Volar distal index finger
Ulnar: Volar distal small finger

Vascular exam:

Radial artery, Ulnar artery

If having difficulty with palpation of radial artery, find a US doppler

Capillary refill to digits

Limited ROM at the shoulder and elbow secondary to pain

AP/Grashey/scapular Y and either axillary or Velpeau views of the shoulder, AP/lateral of the humerus, and AP/lateral of the elbow

Key principle - joint above and below the fracture

Axillary

Beam directed into the axilla
Requires patient to abduct which might be painful in the setting of proximal humerus fracture

Velpeau

Superoinferior view looking down upon shoulder
Does not requires patient to abduct arm

Special views to consider:

Traction view
may be used for fractures with significant comminution, but not routinely indicated

CT scan - not routinely obtained in the ED

Medical Decision Making

Closed humeral shaft fracture:

*** is a *** y/o ***R/L hand-dominant ***M/F with a history of *** presenting with an injury to the ***R/L arm that occured while ***mechanism, found to have a closed humeral shaft fracture. The patient had/did not have*** a radial nerve palsy. On exam, the injury was closed and there was normal capillary refill and a palpable radial pulse. Radiographs revealed ***. The arm was placed in a coaptation splint with a sling. The patient will follow up with orthopaedics in 7-10 days.

Open humeral shaft fracture:

*** is a *** y/o ***R/L hand-dominant ***M/F with a history of *** presenting with an injury to the ***R/L arm that occured while ***mechanism, found to have an open humeral shaft fracture. **IV antibiotics were given immediately upon presentation and tetanus prophylaxis/status was verified. The patient had/did not have*** a radial nerve palsy. There was a laceration that probed to fracture on the *** side of the arm. There was normal capillary refill and a palpable radial pulse. Radiographs revealed ***. Orthopaedics was consulted and will provide recommendations for further management. The patient was made npo and last ate ***.

If open fracture::

Consult orthopaedic surgery immediately
NPO, preop labs (type and screen, INR, aPTT, CBC, BMP)
Ensure IV antibiotics were given (ancef, gentamicin)

Gustillo-Anderson chart for antibiotic type and dose

Concern for compartment syndrome:

Consult orthopaedic surgery immediately
NPO

All other humeral shaft fractures:

WB status: Nonweightbearing injured upper extremity
Diet: Regular
Analgesia: short course of narcotic pain medication, tylenol (scheduled)

Ex: 5mg oxycodone q4 - 25 pills

Immobilization

Coaptation splint and manipulation (vs. Sarmiento brace)

If swelling or varus deformity, use coaptation splint

If grossly angulated apply gentle force to straighten the humerus (typically valgus force)
Generally important to place valgus mold on this splint
These fractures fall into varus so applying a valgus mold helps decrease the risk of this

If minimal swelling, may consider use of sarmiento brace

Less common in the acute setting given swelling

Disposition: Home with follow up in orthopedic surgery clinic in 7-10 days

Materials for Coaptation Splint

Coaptation Splint

Procedure Walkthroughs:

Apply soft padding over elbow, humerus, and shoulder to just above the acromioclavicular (AC) joint
Measure plaster/Ortho-Glass from the axilla, around the elbow, and over the lateral surface of the deltoid
Measure 5 layers of soft padding the length of the measured plaster/Ortho-Glass
Wet the plaster/Ortho-Glass, place the 5 layers of soft padding underneath, and pass the plaster/Ortho-Glass and 5 layers of soft padding through large stockinette with long ends of stockinette on either side
Place the plaster/Ortho-Glass/5 layers of soft padding/stockinette from the axilla, around the elbow, and over the lateral deltoid past the level of the shoulder if possible
Use the long ends of the stockinette to wrap around contralateral shoulder and neck to help hold the plasters position
Wrap the upper arm with an elastic bandage or wrap to further secure the splint

Correct gross angulation of the humerus with gentle traction and pressure opposite the direction of angulation
Apply soft padding over elbow, humerus, and shoulder to just above the acromioclavicular (AC) joint
Measure plaster/Ortho-Glass from the axilla, around the elbow, and over the lateral surface of the deltoid
Measure 5 layers of soft padding the length of the measured plaster/Ortho-Glass
Wet the plaster/Ortho-Glass, place the 5 layers of soft padding underneath, and pass the plaster/Orthoglass and 5 layers of soft padding through large stockinette with long ends of stockinette on either side
Place the plaster/Ortho-Glass/5 layers of soft padding/stockinette from the axilla, around the elbow, and over the lateral deltoid past the level of the shoulder if possible
Use the long ends of the stockinette to wrap around contralateral shoulder and neck to help hold the plaster’s position
Place a valgus mold about the fracture site to prevent the fracture from falling into varus
Wrap the upper arm with elastic bandage or bias to further secure the splint

Procedure Notes:

PROCEDURE NOTE Closed treatment of humeral shaft fracture; without manipulation

PRE-PROCEDURE DIAGNOSIS: fracture of the *** humerus

POST-PROCEDURE DIAGNOSIS: Same (refer above)

PROCEDURALIST: ***

ANESTHESIA: None

NAME OF PROCEDURE: Closed treatment of humeral shaft fracture; without manipulation

PROCEDURE IN DETAIL:
The risks and benefits of the procedure were discussed at length with the patient. Risks discussed included but were not limited to radial nerve entrapment or paresthesias, post-procedural pain, and stiffness. Following informed verbal consent after discussion of risks and benefits, the patient agreed to proceed with the procedure. A timeout was performed.

A well-padded coaptation splint was applied to the injured extremity. A valgus mold was slowly applied as the splint hardened. Post splinting radiographs showed acceptable alignment after the splint application. The patient's neurovascular status was consistent with baseline.

COMPLICATIONS: None

DISPOSITION: Discharged home with follow up with orthopaedic surgery in 7-10 days for repeat evaluation

PROCEDURE NOTE Closed treatment of humeral shaft fracture; with manipulation

PRE-PROCEDURE DIAGNOSIS: fracture of the *** humerus

POST-PROCEDURE DIAGNOSIS: Same (refer above)

PROCEDURALIST: ***

ANESTHESIA: None

NAME OF PROCEDURE: Closed treatment of humeral shaft fracture; with manipulation

PROCEDURE IN DETAIL:
The risks and benefits of the procedure were discussed at length with the patient. Risks discussed included but were not limited to radial nerve entrapment or paresthesias, post-procedural pain, and stiffness. Following informed verbal consent after discussion of risks and benefits, the patient agreed to proceed with the procedure. A timeout was performed.

The angulation of the humerus was corrected with traction and gentle pressure opposite the direction of angulation. A well-padded coaptation splint was then applied to the injured extremity with a valgus mold as the splint hardened. Post manipulation radiographs showed improved alignment. The patient's neurovascular status was consistent with baseline.

COMPLICATIONS: None

DISPOSITION: Discharged home with follow up with orthopaedic surgery in 7-10 days for repeat evaluation

Common ICD-10 Codes	Brief Description
S42.3	Fracture of shaft of humerus
S42.31	Greenstick fracture of shaft of humerus
S42.32	Transverse fracture of shaft of humerus
S42.33	Oblique fracture of shaft of humerus
S42.34	Spiral fracture of shaft of humerus
S42.35	Comminuted fracture of shaft of humerus
S42.36	Segmental fracture of shaft of humerus