Treatment of Humerus Fractures
Critical Distinction: Pediatric vs. Adult Fractures
The treatment approach fundamentally differs based on patient age and fracture location, requiring immediate classification before proceeding.
Pediatric Supracondylar Humerus Fractures
Nondisplaced Fractures (Gartland Type I)
Use posterior splint immobilization rather than collar-and-cuff for nondisplaced pediatric supracondylar fractures to optimize pain control and prevent displacement. 1
- Posterior splint/back-slab immobilization provides superior pain relief within the first 2 weeks compared to collar-and-cuff methods 1
- This applies to acute nondisplaced fractures or those with only a posterior fat pad sign 1
Displaced Fractures (Gartland Type II and III)
Perform closed reduction with percutaneous Kirschner wire pinning for all displaced Type II and III supracondylar fractures, as this is the preferred treatment to prevent limb-threatening complications. 1
- Closed reduction and pinning demonstrates superior outcomes for preventing cubitus varus deformity (number needed to treat = 20) 1
- Flynn's elbow criteria outcomes are significantly better with surgical fixation (NNT = 7) 1
- While iatrogenic ulnar nerve injury can occur with surgery (number needed to harm = 108), the catastrophic risks of nonoperative management—including limb-threatening ischemia from hyperflexion casting—far outweigh surgical risks 1
Vascular Compromise Management
If the hand remains pale and pulseless after closed reduction and pinning, immediately perform open exploration of the antecubital fossa to prevent limb loss. 1
- Most displaced fractures with vascular compromise improve after reduction, but persistent underperfusion mandates surgical exploration 1
- The catastrophic risks of inadequate perfusion include limb loss, ischemic muscle contracture (Volkmann's), nerve injury, and permanent functional deficit 1
- Benefits of immediate exploration clearly outweigh potential surgical harms (infection, neurovascular injury, stiffness) when dealing with a cold, pale hand 1
- Consider vascular surgery consultation and utilize the AAOS mobile application for real-time decision support regarding specific vascular status scenarios 1
Common Pitfall: Delaying exploration in a child with persistent vascular compromise after reduction can result in irreversible ischemic injury within hours.
Adult Humerus Fractures
Proximal Humerus Fractures
Most proximal humerus fractures in adults should be treated nonoperatively with short-term immobilization followed by early physical therapy, reserving surgery for significantly displaced or complex fractures. 2, 3
- The majority of proximal humerus fractures achieve good functional results with nonoperative management 3
- Surgical options include locking plates, intramedullary nailing, percutaneous fixation, or arthroplasty depending on fracture pattern, bone quality, and patient factors 2, 3
- Locking plates show favorable results for displaced, comminuted fractures and may reduce the need for hemiarthroplasty in some cases 3
- Patient age, health status, bone quality, and surgeon expertise critically influence treatment selection 2, 4
Humeral Shaft Fractures
Treat simple humeral shaft fractures (AO/OTA Type A) with open reduction and internal fixation using compression plating, as current evidence shows unacceptably high nonunion rates with conservative functional bracing. 5, 6
- Recent evidence demonstrates increasing nonunion rates after conservative treatment, suggesting traditional indications for functional bracing need re-examination 5
- Conservative treatment with functional bracing historically achieved union in >94% of cases within 10 weeks, but this success rate is declining 6
- Angulation tolerance: up to 30° varus/valgus and 20° flexion/extension deformity is functionally acceptable 6
Surgical Treatment Algorithm:
- Simple fractures (Type A): ORIF with compression plating 5
- Complex/comminuted fractures: Minimally invasive plate osteosynthesis (MIPO) to preserve periosteal blood supply and promote secondary bone healing 5
- Alternative option: Intramedullary nailing (antegrade or retrograde) achieves union in 10-15 weeks with 2-17.4% nonunion rate 5, 6
Plate fixation outcomes: Union in 11-19 weeks, with 2.8-21% nonunion, 6.5-12% secondary radial nerve palsy, and 0.8-2.4% infection rates 6
Radial Nerve Palsy Management
When radial nerve palsy accompanies a humeral shaft fracture, explore the nerve surgically if the fracture is open, significantly displaced, associated with vascular injury, or requires surgical fixation for other reasons. 6
- Ultrasound can reliably detect nerve contusion, entrapment, or laceration with accuracy comparable to intraoperative findings 5
- For closed, minimally displaced fractures without surgical indications, management of radial nerve palsy remains controversial with no clear consensus 6
Common Pitfall: Assuming all radial nerve palsies require immediate exploration—most iatrogenic palsies from closed reduction resolve spontaneously, but those associated with open fractures or vascular injury demand urgent surgical assessment.
Key Decision Points
- Age determines approach: Pediatric supracondylar fractures require aggressive surgical management of displaced fractures; adult fractures favor initial conservative management
- Displacement severity: Any pediatric displacement (Type II/III) = surgery; adult displacement requires individualized assessment based on fracture pattern and patient factors
- Vascular status: Persistent underperfusion after reduction = immediate surgical exploration regardless of age 1
- Fracture location: Supracondylar (pediatric emergency), proximal (often nonoperative in adults), shaft (increasingly surgical in adults) 5, 2, 6