What is the treatment for a patient with a humerus fracture?

Treatment of Humerus Fractures

Critical Distinction: Pediatric vs. Adult Fractures

The treatment approach for humerus fractures differs fundamentally based on patient age and fracture location. The available evidence primarily addresses pediatric supracondylar fractures, which represent a specific subset requiring distinct management from adult humeral shaft or proximal humerus fractures.

---

Pediatric Supracondylar Humerus Fractures

Nondisplaced Fractures (Gartland Type I)

For nondisplaced or minimally displaced pediatric supracondylar fractures, immobilization with a posterior splint (back-slab) is recommended over collar-and-cuff immobilization. 1

• Posterior splint immobilization provides superior pain relief within the first 2 weeks compared to collar-and-cuff methods 1
• This recommendation is based on moderate-quality evidence from randomized controlled trials 1

Displaced Fractures (Gartland Types II and III)

Closed reduction with percutaneous Kirschner wire pinning is the preferred treatment for displaced pediatric supracondylar fractures. 1

• This approach demonstrates superior outcomes regarding:

  • Prevention of cubitus varus deformity (NNT = 20) 1
  • Better Flynn's elbow criteria scores (NNT = 7) 1
  • Reduced risk of limb-threatening ischemia from hyperflexion casting 1

• The trade-off is a small risk of iatrogenic ulnar nerve injury (NNH = 108) 1

Pin configuration: Two or three laterally introduced pins are suggested to stabilize the reduction, with consideration to avoid medial pin placement due to potential nerve injury risk 1

Vascular Compromise Management

Critical emergency situations require immediate intervention:

• If absent wrist pulses with cold, pale hand persist after reduction and pinning, immediate open exploration of the antecubital fossa is indicated 1
• The catastrophic risks of persistent inadequate perfusion (limb loss, ischemic contracture, nerve injury) outweigh surgical risks 1
• For absent pulses but perfused hand after reduction, evidence is insufficient to make definitive recommendations 1

---

Adult Humeral Shaft Fractures

Conservative Management

Functional bracing remains an effective option for appropriate humeral shaft fractures, though recent evidence suggests increasing nonunion rates may warrant re-examination of indications. 2

• Humeral fracture braces permit greater functional use of the limb without affecting fracture healing and alignment 3
• Fracture bracing demonstrates superior elbow range of motion (11°-126°) compared to plaster U-slab immobilization (50°-119°) at time of union 3

Surgical Indications

Surgical fixation should be considered for:

• Fractures with increasing nonunion risk with conservative treatment 2
• Open fractures, polytrauma, vascular injury, or failed conservative management 2

Surgical options include: 2

• Open reduction and internal fixation (ORIF) with compression plates for simple/AO type A fractures
• Minimally invasive plate osteosynthesis (MIPO) for preserving periosteal blood supply and achieving secondary bone healing
• Intramedullary nailing (IMN) as an alternative, though historically limited by shoulder impingement and technical challenges

---

Proximal Humerus Fractures (Adult)

Immobilization Position

For proximal humerus fractures requiring immobilization, neutral-rotation bracing shows trends toward superior outcomes compared to traditional internal rotation slings. 4

• Neutral-rotation bracing demonstrates better range of motion at 1 year (elevation 159°, external rotation 47°) versus simple sling (140°, 37°) 4
• Functional scores trend better with neutral-rotation bracing (DASH 35 vs 42, Constant-Murley 86 vs 71) 4

Postoperative Rehabilitation After ORIF

For operatively treated proximal humerus fractures with locking plates, early active motion protocols are not inferior to restrictive immobilization. 5

• Early functional rehabilitation without movement restrictions achieves equivalent outcomes to 4-week immobilization protocols 5
• At 24 months, both approaches show similar Constant scores (81.3 vs 77.6) and relative Constant scores (89.8% of uninjured side) 5
• Virtual reality-based rehabilitation as adjunct to conventional therapy improves shoulder ROM, muscle strength, and upper limb function more than conventional therapy alone 6

---

Key Clinical Pitfalls

• Avoid hyperflexion casting in displaced pediatric supracondylar fractures due to risk of limb-threatening ischemia 1
• Monitor vascular status meticulously in all supracondylar fractures, as this represents the most serious complication risk 1
• Recognize that conservative treatment failure rates may be higher than historically appreciated for humeral shaft fractures 2
• Ultrasound can reliably detect radial nerve conditions (contusion, entrapment, laceration) with accuracy comparable to intraoperative findings 2