What is the typical treatment for a midshaft humerus fracture?

Treatment of Midshaft Humerus Fractures

The typical treatment for midshaft humerus fractures is functional bracing after initial immobilization with either a coaptation splint or functional splint, as this approach provides high union rates with acceptable functional outcomes. 1, 2

Initial Assessment and Management

• Initial immobilization options:

  • Functional splint (FS): Easier to apply, takes less time, and is better tolerated by patients 2
  • Coaptation splint (CS): Traditional option but more difficult to apply
  • Both provide similar fracture reduction results with no clinically relevant differences in fracture angulation or translation 2

• Duration of initial immobilization:

  • Average of 9 days (range 0-35 days) before transitioning to functional bracing 3

Definitive Treatment Algorithm

1. Non-operative Management (First-line for most cases)

• Functional bracing: Prefabricated brace that permits full motion of adjacent joints
• Advantages:
  • High union rates (98% for closed fractures, 94% for open fractures) 3
  • Allows early mobilization of shoulder and elbow
  • Functionally and aesthetically acceptable angular deformities in most cases
  • Avoids surgical risks

2. Surgical Management (Reserved for specific indications)

• Indications for surgery:

  • Open fractures with significant soft tissue damage
  • Polytrauma patients
  • Floating elbow injuries
  • Pathological fractures
  • Bilateral fractures
  • Fractures with vascular injury
  • Unacceptable alignment after closed reduction
  • Patient preference in certain cases

• Surgical options:

  • Open Reduction Internal Fixation (ORIF): Best for simple or AO/OTA type A fractures 1
  • Minimally Invasive Plate Osteosynthesis (MIPO): Less invasive, preserves periosteal blood supply, allows indirect bone healing with callus formation 1
  • Intramedullary Nailing (IMN): Gaining popularity with improved implant designs and techniques 1

Rehabilitation Protocol

• Early finger motion is encouraged to minimize stiffness
• Progressive mobilization of shoulder and elbow as pain allows
• Virtual rehabilitation combined with conventional physical therapy shows superior outcomes for improving range of motion, muscle strength, and upper limb function compared to conventional therapy alone 4

Monitoring and Follow-up

• Regular radiographic assessment until fracture union
• Monitor for:
  • Nonunion (2% risk in closed fractures, 6% risk in open fractures) 3
  • Angular deformities (acceptable if <16° varus on AP view and <16° anterior angulation on lateral view) 3
  • Shoulder motion limitations (98% of patients have ≤25° limitation at brace removal) 3
  • Radial nerve palsy (can be assessed with ultrasound if suspected) 1

Clinical Pearls and Pitfalls

• Important clinical pearl: Functional bracing allows for early mobilization while maintaining adequate stability for fracture healing
• Common pitfall: Missing a new fracture during rehabilitation of a previous injury, as demonstrated in a case where a midshaft humeral fracture occurred during rehabilitation of a proximal humeral fracture 5
• Caution: Increasing pain, regression in range of motion, or functional decline during rehabilitation should prompt consideration of imaging to rule out a new fracture or displacement 5

Special Considerations

• The trend in treatment has been shifting toward more surgical management due to concerns about nonunion rates with conservative treatment, but functional bracing remains the mainstay of treatment for most uncomplicated midshaft humeral fractures 1
• Careful patient selection for non-operative versus operative management is crucial for optimal outcomes