What is the treatment for a humerus fracture?

Treatment of Humerus Fractures

The treatment of humerus fractures depends on the fracture location, patient age, and fracture stability, with most proximal humeral fractures being treated non-operatively with good functional outcomes, while displaced fractures may require surgical fixation. 1

Treatment Based on Fracture Location

Proximal Humerus Fractures

• Most proximal humeral fractures can be treated non-operatively with good functional outcomes 2
• Treatment options for displaced fractures include:
  • Open reduction and internal fixation with locking plates for displaced, comminuted fractures 2, 1
  • Hemiarthroplasty for severely displaced fractures in frail patients 2
  • Reverse shoulder arthroplasty for geriatric patients with pre-existing rotator cuff dysfunction 2

Humeral Shaft Fractures

• Can be treated either conservatively with functional bracing or with surgical fixation 3
• Surgical options include:
  • Open reduction and internal fixation (ORIF) with compression plates for simple or AO/OTA type A fractures 3
  • Minimally invasive plate osteosynthesis (MIPO) for less invasive approach that preserves periosteal blood supply 3
  • Intramedullary nailing (IMN) as an alternative option with newer implant designs 3

Distal Humerus Fractures

• Surgical treatment is optimal for most distal humerus fractures 4
• Fixation with two precontoured anatomical locking plates at 90°:90° orthogonal or 180° parallel is the preferred treatment 4
• The main goal is to obtain stable fixation to allow immediate postoperative elbow mobilization and prevent joint stiffness 4

Special Considerations for Pediatric Humerus Fractures

• For pediatric proximal humerus fractures, treatment should be based on fracture displacement and patient age 5
• Treatment options include:
  • Conservative treatment for minimally displaced fractures 5
  • Elastic Stable Intramedullary Nailing (ESIN) for severely displaced fractures (Neer grade III/IV, angulation ≥ 20°), showing a 98% success rate 5
  • K-wire fixation as an alternative surgical option with 95% success rate 5

Management of Complications

Vascular Injury with Pediatric Supracondylar Humerus Fractures

• In patients with absent wrist pulses and underperfusion after reduction and pinning, open exploration of the antecubital fossa is recommended 2
• For patients with a perfused hand but absent wrist pulses after reduction, the evidence is inconclusive regarding the need for exploration 2
• Appropriate treatments for vascular injury may include 2:
  • Warming the extremity
  • Assessment by a vascular surgeon
  • Exploration of the fracture site for brachial artery entrapment
  • In-hospital observation for at least 24 hours after vascularity is restored

Other Common Complications

• Mechanical failure, ulnar neuropathy, stiffness, heterotopic ossification, nonunion, malunion, and infection are common complications of distal humerus fracture treatment 4
• Radial nerve palsy can be evaluated using ultrasound with reliability comparable to intraoperative findings 3

Rehabilitation Considerations

• Early active motion is critical to prevent stiffness 6
• The optimal time for removal of pins and mobilization in patients with displaced pediatric supracondylar fractures remains inconclusive 2
• Regular radiographic evaluation during follow-up is recommended to ensure proper healing 6

Clinical Pitfalls and Caveats

• Decision-making should be based on patient factors, injury specifics, and surgeon's experience 1
• Anatomic reduction can be difficult, and loss of fixation due to poor bone quality may lead to fracture displacement and malunion 7
• Hemiarthroplasty has risks of shoulder stiffness, tuberosity resorption, and glenohumeral instability 7
• For ESIN in pediatric fractures, using a two-nail technique rather than a one-nail technique significantly reduces complications 5