What is the treatment for a humeral spiral fracture?

Treatment of Humeral Spiral Fractures

For humeral spiral fractures, closed reduction with percutaneous Kirschner wire pinning is the preferred treatment for displaced fractures, while non-displaced fractures may be managed conservatively with appropriate immobilization. 1

Assessment and Classification

• Evaluate for:

  • Displacement of fracture fragments
  • Vascular compromise (absent wrist pulses, cold/pale hand, decreased perfusion)
  • Neurological status (particularly radial nerve function)
  • Associated injuries

• Spiral fractures with large butterfly fragments (especially medial) require special attention as they may be unstable and have higher risk of non-union 2

Treatment Algorithm

For Non-displaced Spiral Fractures:

1. Conservative management with immobilization
   • Arm sling is generally more comfortable than body bandage 3
   • Early mobilization (at 1 week) rather than delayed (3 weeks) results in less pain without compromising outcomes 3
   • Provide adequate instruction for self-directed exercise program 3

For Displaced Spiral Fractures:

1. Closed reduction with percutaneous pin fixation is the preferred treatment 1

   • Provides better outcomes regarding prevention of deformity and improved functional criteria 1
   • Two or three laterally introduced pins are typically used to stabilize the reduction 3

2. For fractures with large medial butterfly fragments:

   • Open reduction and plate-screw fixation is recommended to achieve anatomical reduction 2
   • Important to fix the medial fragment anatomically to achieve union without disturbing vascular supply 2

For Fractures with Vascular Compromise:

1. Urgent closed reduction is mandatory as this is a limb-threatening emergency 1
2. Reassess vascular status after reduction:
   • If perfusion improves and pulses return: proceed with definitive fixation
   • If perfusion remains poor: immediate surgical exploration of antecubital fossa 1

Special Considerations

• Radial nerve injury: Common with spiral humeral fractures

  • In cases with atypical nerve injuries (nerve entrapment by bone fragments), surgical exploration may be necessary 4
  • Conservative management may be insufficient for cases where the nerve is penetrated by bone fragments 4

• Sports-related spiral fractures:

  • Often result from rotational forces (arm wrestling, falls during cycling/skiing) 5, 6
  • Can be managed non-operatively if displacement is minimal 6
  • Mean time to radiographic union is approximately 13.6 weeks 6

Rehabilitation

• Early finger motion is encouraged to minimize stiffness 1
• While there is insufficient evidence to recommend routine supervised physical therapy, adequate self-directed exercise programs can achieve satisfactory outcomes 3
• Optimal timing for allowing unrestricted activity remains unclear and should be based on clinical and radiographic evidence of healing 3

Complications to Monitor

• Radial nerve injury (particularly with spiral fractures)
• Non-union or delayed union
• Pin tract infection if surgical fixation used
• Loss of reduction
• Vascular compromise
• Stiffness of adjacent joints

The treatment approach should prioritize anatomic reduction, stable fixation, and early mobilization to optimize functional outcomes while minimizing complications.