A humerus fracture is a break of the humerus bone in the upper

arm In human anatomy, the arm refers to the upper limb in common usage, although academically the term specifically means the upper arm between the glenohumeral joint (shoulder joint) and the elbow joint. The distal part of the upper limb between th ...

. Symptoms may include pain, swelling, and

bruising A bruise, also known as a contusion, is a type of hematoma of tissue, the most common cause being capillaries damaged by trauma, causing localized bleeding that extravasates into the surrounding interstitial tissues. Most bruises occur close ...

. There may be a decreased ability to move the arm and the person may present holding their elbow. Complications may include injury to an artery or nerve, and compartment syndrome. The cause of a humerus fracture is usually

physical trauma An injury is any physiological damage to living tissue caused by immediate physical stress. An injury can occur intentionally or unintentionally and may be caused by blunt trauma, penetrating trauma, burning, toxic exposure, asphyxiation, or ...

such as a

fall Autumn, also known as fall in American English and Canadian English, is one of the four temperate seasons on Earth. Outside the tropics, autumn marks the transition from summer to winter, in September (Northern Hemisphere) or March ( Southe ...

. Other causes include conditions such as cancer in the bone. Types include proximal humeral fractures, humeral shaft fractures, and distal humeral fractures. Diagnosis is generally confirmed by

X-ray An X-ray, or, much less commonly, X-radiation, is a penetrating form of high-energy electromagnetic radiation. Most X-rays have a wavelength ranging from 10 picometers to 10 nanometers, corresponding to frequencies in the range 30 ...

s. A CT scan may be done in proximal fractures to gather further details. Treatment options may include a

sling sling may refer to: Places * Sling, Anglesey, Wales * Sling, Gloucestershire, England, a small village in the Forest of Dean People with the name * Otto Šling (1912–1952), repressed Czech communist functionary Arts, entertainment, and media ...

, splint,

brace Brace(s) or bracing may refer to: Medical * Orthopaedic brace, a device used to restrict or assist body movement ** Back brace, a device limiting motion of the spine *** Milwaukee brace, a kind of back brace used in the treatment of spinal c ...

, or surgery. In proximal fractures that remain well aligned, a sling is often sufficient. Many humerus shaft fractures may be treated with a brace rather than surgery. Surgical options may include

open reduction and internal fixation Internal fixation is an operation in orthopedics that involves the surgical implementation of implants for the purpose of repairing a bone, a concept that dates to the mid-nineteenth century and was made applicable for routine treatment in the ...

, closed reduction and percutaneous pinning, and

intramedullary nail The medullary cavity (''medulla'', innermost part) is the central cavity of bone shafts where red bone marrow and/or yellow bone marrow (adipose tissue) is stored; hence, the medullary cavity is also known as the marrow cavity. Located in the ma ...

ing.

Joint replacement Replacement arthroplasty (from Greek ''arthron'', joint, limb, articulate, + ''plassein'', to form, mould, forge, feign, make an image of), or joint replacement surgery, is a procedure of orthopedic surgery in which an arthritic or dysfunctional j ...

may be another option. Proximal and shaft fractures generally have a good outcome while outcomes with distal fractures can be less good. They represent about 4% of fractures.

Signs and symptoms

$Upper arm bone fracture - Humerus fracture 2 -- Smart-Servier$ After a humerus fracture, pain is immediate, enduring, and exacerbated with the slightest movements. The affected region swells, with bruising appearing a day or two after the fracture. The fracture is typically accompanied by a discoloration of the skin at the site of the fracture.Cameron, et al., 2014, p. 167–170 A crackling or rattling sound may also be present, caused by the fractured humerus pressing against itself. In cases in which the nerves are affected, then there will be a loss of control or sensation in the arm below the fracture. If the fracture affects the blood supply, then the patient will have a diminished pulse at the wrist. Displaced fractures of the humerus shaft will often cause deformity and a shortening of the length of the upper arm. Distal fractures may also cause deformity, and they typically limit the ability to flex the elbow.

Causes

Humerus fractures usually occur after physical trauma, falls, excess physical stress, or pathological conditions. Falls that produce humerus fractures among the elderly are usually accompanied by a preexisting risk factor for bone fracture, such as osteoporosis, a low bone density, or vitamin B deficiency.

Proximal

Proximal humerus fractures most often occur among elderly people with osteoporosis who fall on an outstretched arm. Less frequently, proximal fractures occur from motor vehicle accidents, gunshots, and violent muscle contractions from an electric shock or

seizure An epileptic seizure, informally known as a seizure, is a period of symptoms due to abnormally excessive or synchronous neuronal activity in the brain. Outward effects vary from uncontrolled shaking movements involving much of the body with los ...

.Auth, 2012, p. 167 Other risk factors for proximal fractures include having a low

bone mineral density Bone density, or bone mineral density, is the amount of bone mineral in bone tissue. The concept is of mass of mineral per volume of bone (relating to density in the physics sense), although clinically it is measured by proxy according to optical ...

, having impaired vision and balance, and

tobacco smoking Tobacco smoking is the practice of burning tobacco and ingesting the resulting smoke. The smoke may be inhaled, as is done with cigarettes, or simply released from the mouth, as is generally done with pipes and cigars. The practice is believe ...

.Crosby, et al., 2014, p. 23 A

stress fracture A stress fracture is a fatigue-induced bone fracture caused by repeated stress over time. Instead of resulting from a single severe impact, stress fractures are the result of accumulated injury from repeated submaximal loading, such as running or ...

of the proximal and shaft regions can occur after an excessive amount of throwing, such as pitching in baseball.Cuccurullo, 2014, p. 178

Middle

Middle fractures are usually caused by either physical trauma or falls. Physical trauma to the humerus shaft tends to produce transverse fractures whereas falls tend to produce spiral fractures. Metastatic breast cancer may also cause fractures in the humerus shaft. Long spiral fractures of the shaft that are present in children may indicate physical abuse.

Distal

Distal humerus fractures usually occur as a result of physical trauma to the elbow region. If the elbow is bent during the trauma, then the

olecranon The olecranon (, ), is a large, thick, curved bony eminence of the ulna, a long bone in the forearm that projects behind the elbow. It forms the most pointed portion of the elbow and is opposite to the cubital fossa or elbow pit. The olecranon ...

is driven upward, producing a T- or Y-shaped fracture or displacing one of the condyles.

Diagnosis

Definitive diagnosis of humerus fractures is typically made through radiographic imaging. For proximal fractures,

s can be taken from a

scapula The scapula (plural scapulae or scapulas), also known as the shoulder blade, is the bone that connects the humerus (upper arm bone) with the clavicle (collar bone). Like their connected bones, the scapulae are paired, with each scapula on eithe ...

r anteroposterior (AP) view, which takes an image of the front of the shoulder region from an angle, a scapular Y view, which takes an image of the back of the shoulder region from an angle, and an axillar lateral view, which has the patient lie on his or her back, lift the bottom half of the arm up to the side, and have an image taken of the

axilla The axilla (also, armpit, underarm or oxter) is the area on the human body directly under the shoulder joint. It includes the axillary space, an anatomical space within the shoulder girdle between the arm and the thoracic cage, bounded super ...

region underneath the shoulder. Fractures of the humerus shaft are usually correctly identified with radiographic images taken from the AP and lateral viewpoints. Damage to the radial nerve from a shaft fracture can be identified by an inability to bend the hand backwards or by decreased sensation in the back of the hand. Images of the distal region are often of poor quality due to the patient being unable to extend the elbow because of pain. If a severe distal fracture is suspected, then a computed tomography (CT) scan can provide greater detail of the fracture. Nondisplaced distal fractures may not be directly visible; they may only be visible due to

fat In nutrition, biology, and chemistry, fat usually means any ester of fatty acids, or a mixture of such compounds, most commonly those that occur in living beings or in food. The term often refers specifically to triglycerides (triple est ...

being displaced because of internal bleeding in the elbow. File:GreatertrochanerAP.png, A fracture of the greater tuberosity as seen on AP X ray File:GreatertrochanerY.png, A fracture of the greater tuberosity of the humerus File:FractureTrochanter.png, Fracture of the greater tuberosity of the humerus File:ProxHumeralFracture.png, Multi-fragmented, or comminuted fracture of the proximal humerus with involvement of the greater tuberosity File:Proxhumerousfrac.png, Proximal humerus fracture File:MidShaftHumerousMark.png, A transverse fracture of the humerus shaft File:Spiralbruch.png, A spiral fracture of the distal one-third of the humerus shaft File:Supracondylar09.JPG, A displaced supracondylar fracture in a child

Classification

Fractures of the humerus are classified based on the location of the fracture and then by the type of fracture. There are three locations that humerus fractures occur: at the proximal location, which is the top of the humerus near the shoulder, in the middle, which is at the shaft of the humerus, and the distal location, which is the bottom of the humerus near the elbow.Cameron, et al., 2014, p. 167 Proximal fractures are classified into one of four types of fractures based on the displacement of the greater tubercle, the lesser tubercle, the surgical neck, and the anatomical neck, which are the four parts of the proximal humerus, with fracture displacement being defined as at least one centimeter of separation or an angulation greater than 45 degrees. One-part fractures involve no displacement of any parts of the humerus, two-part fractures have one part displaced relative to the other three; three-part fractures have two displaced fragments, and four-part fractures have all fragments displaced from each other.Cuccurullo, 2014, p. 177 Fractures of the humerus shaft are subdivided into transverse fractures, spiral fractures, "butterfly" fractures, which are a combination of transverse and spiral fractures, and pathological fractures, which are fractures caused by medical conditions.Cameron, et al., 2014, p. 169 Distal fractures are split between supracondylar fractures, which are transverse fractures above the two

condyles A condyle (;Entry "condyle"
in

Proximal

One-part and two-part proximal fractures can be treated with a collar and cuff sling, adequate pain medicine, and follow up therapy. Two-part proximal fractures may require open or closed reduction depending on neurovascular injury,

rotator cuff The rotator cuff is a group of muscles and their tendons that act to stabilize the human shoulder and allow for its extensive range of motion. Of the seven scapulohumeral muscles, four make up the rotator cuff. The four muscles are the supra ...

injury, dislocation, likelihood of union, and function. For three- and four-part proximal fractures, standard practice is to have open reduction and internal fixation to realign the separate parts of the proximal humerus. A humeral hemiarthroplasty may be required in proximal cases in which the blood supply to the region is compromised. Compared with non-surgical treatment, surgery does not result in a better outcome for the majority of people with displaced proximal humeral fractures and is likely to result in a greater need for subsequent surgery.

Middle

Fractures of the humerus shaft are most often uncomplicated, closed fractures that require nothing more than pain medicine and wearing a

cast Cast may refer to: Music * Cast (band), an English alternative rock band * Cast (Mexican band), a progressive Mexican rock band * The Cast, a Scottish musical duo: Mairi Campbell and Dave Francis * ''Cast'', a 2012 album by Trespassers William ...

or sling. For midshaft fractures up to 12 weeks may be required for healing. In shaft and distal cases in which complications such as damage to the neurovascular bundle exist, then surgical repair is required.

Prognosis

In most cases, people are discharged from an emergency department with pain medicine and a cast or sling. These fractures are typically minor and heal over the course of a few weeks. Fractures of the proximal region, especially among elderly people, may limit future shoulder activity. Severe fractures are usually resolved with surgical intervention, followed by a period of healing using a cast or sling. Severe fractures often cause long-term loss of physical ability.Crosby, et al., 2014, p. 35 Complications in the recovery process of severe fractures include osteonecrosis, malunion or

nonunion Nonunion is permanent failure of healing following a broken bone unless intervention (such as surgery) is performed. A fracture with nonunion generally forms a structural resemblance to a fibrous joint, and is therefore often called a "false j ...

of the fracture, stiffness, and rotator cuff dysfunction, which require additional intervention in order for the patient to fully recover.

Epidemiology

Humerus fractures are among the most common of fractures. Proximal fractures make up 5% of all fractures and 25% of humerus fractures, middle fractures about 60% of humerus fractures (12% of all fractures), and distal fractures the remainder. Among proximal fractures, 80% are one-part, 10% are two-part, and the remaining 10% are three- and four-part. The most common location of proximal fractures is at the surgical neck of the humerus. Incidence of proximal fractures increases with age, with about 75% of cases occurring among people over the age of 60. In this age group, about three times as many women than men experience a proximal fracture.Crosby, et al., 2014, p. 1 Middle fractures are also common among the elderly, but they frequently occur among physically active young adult men who experience physical trauma to the humerus. Distal fractures are rare among adults, occurring primarily in children who experience physical trauma to the elbow region.

References

Bibliography

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External links

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