J Shoulder Elbow Surg (2018) 27, e87–e97

www.elsevier.com/locate/ymse

ONLINE ARTICLES

Humeral shaft fractures

Gary F. Updegrove, MDa, Wassim Mourad, MDb, Joseph A. Abboud, MDa,*

a
The Rothman Institute, Philadelphia, PA, USA
b
Division of Orthopedic Surgery, American University of Beirut Medical Center, Beirut, Lebanon

Fractures of the humeral shaft are common injuries with multiple management strategies. Many still regard
nonoperative management as the standard of care; however, as the understanding of these injuries in-
creases, treatment recommendations are also evolving. Fracture pattern, fracture location, and identifiable
patient risk factors may predict poor outcome with nonoperative management, and earlier operative in-
tervention may be recommended. Operative management includes open reduction and internal fixation through
a variety of exposures, intramedullary nail fixation, and external fixation. With increasing rates of shoul-
der arthroplasty, periprosthetic humeral shaft fractures also deserve special consideration.
Level of evidence: Narrative Review
© 2017 Journal of Shoulder and Elbow Surgery Board of Trustees. All rights reserved.
Keywords: Humerus; shaft; fracture; bracing; fixation; periprosthetic

Epidemiology located just distal to the midpoint of the bone on the

anteromedial border between the insertion of the coracobra-
Fractures of the humerus comprise approximately 5% to 8% chialis and the origin of the brachialis muscle.75
of all extremity fractures, and shaft fractures account for ap- The shaft of the humerus (corpus humeri) is almost cy-
proximately 3% of all long-bone fractures.13,70 The incidence lindrical in its proximal half and then becomes flattened
of humeral shaft fractures is approximately 13 per 100,000 and triangular distally. It has 3 major surfaces: anterolat-
persons per year.9 eral, anteromedial, and posterior.67 The primary areas of
surgical importance are the deltoid tuberosity and the radial
Anatomy groove. The deltoid tuberosity is an elevation near the middle
of the anterolateral surface, onto which the deltoid muscle
inserts. The radial groove or sulcus (musculospiral groove)
The humeral shaft is commonly defined as the segment distal
starts distal to the attachment of the lateral head of triceps
to the surgical neck and proximal to the epicondyles.28 Knowl-
on the posterior surface and runs distal and lateral toward
edge of the complex neurovascular anatomy of the arm is
the anterolateral surface. Both the radial nerve and pro-
imperative to accomplish a safe surgical approach.78 Surgi-
funda artery pass within this groove.
cal landmarks that warrant attention during exposure of the
With a primary radial nerve injury rate ranging from 4%
humeral shaft are the axillary nerve and the brachial artery
to 22% in the literature and an iatrogenic surgical injury rate
proximally, and the median, ulnar, and radial nerves distally.78
of almost 3%, the radial nerve deserves special attention.26,48
The main blood supply of the shaft is via a nutrient artery,
It arises from the posterior cord of the brachial plexus and
runs anterior to the subscapularis muscle to penetrate the tri-
*Reprint requests: Joseph A. Abboud, MD, Shoulder & Elbow Division,
The Sidney Kimmel Medical College at Thomas Jefferson University, 925
angular interval in conjunction with the deep brachial artery.
Chestnut, 5th Flr, Philadelphia, PA 19107, USA. At an average distance of 9.7 to 14.2 cm from the acro-
E-mail address: joseph.abboud@rothmaninstitute.com (J.A. Abboud). mion, both structures travel side by side in the radial groove

1058-2746/$ - see front matter © 2017 Journal of Shoulder and Elbow Surgery Board of Trustees. All rights reserved.
https://doi.org/10.1016/j.jse.2017.10.028
e88 G.F. Updegrove et al.

in a plane between the medial and lateral heads of the triceps The brachial artery and the median nerve have a joint course
muscle. Then, the radial nerve travels adjacent to the poste- along the humeral shaft. Both are rarely encountered during
rior aspect of the humerus for 6.5 cm.18 It exits the spiral groove humeral shaft exposure. The median nerve arises from the
on average 12.6 cm (range, 10.1-14.8 cm) proximal to the lateral and medial cords of the brachial plexus and courses
lateral epicondyle and 18.1 to 20.7 cm proximal to the medial directly medial to the brachial artery along the anterior surface
epicondyle.21,29,40,78 As the radial nerve exits the spiral groove of the intermuscular septum. Distally, both structures travel
and penetrates through the lateral intermuscular septum into in the interval between the pronator teres and the biceps tendon.78
the anterior compartment, it is located an average of 10 cm The ulnar nerve, originating from the medial cord, also
from the distal articular surface of the elbow but never closer courses anterior to the medial intermuscular septum. It then
than 7.5 cm.40 This is the location at which the Holstein- crosses posteriorly at the arcade of the Struthers, 8 cm prox-
Lewis fracture can potentially injure the nerve. 25 After imal to the medial epicondyle. From there on, the ulnar nerve
penetrating the lateral intermuscular septum, the radial nerves travels posterior to the intermuscular septum, behind the medial
gives rise to the posterior antebrachial cutaneous nerve that epicondyle, and into the cubital tunnel.78
course towards the forearm on the posterior aspect of the
septum.78 In the distal arm, the radial nerve courses between
the brachioradialis and the brachialis muscle (Fig. 1).78 Physical examination
The axillary nerve arises from the posterior cord of the
brachial plexus. It courses anterior to the subscapularis muscle, Basic principles are used for patients presenting with humeral
wraps posteriorly around the surgical neck of the humerus, shaft fractures. A skin examination is used to assess for
and penetrates the quadrangular space, innervating the teres an open fracture or gross deformity. Then, a vascular
minor and deltoid muscles. The axillary nerve is traced an examination is important to confirm the integrity of the radial
average of 4.3 to 7.4 cm distal to the lateral acromial edge and ulnar arteries. A neurologic examination should be per-
as it loops around the surgical neck.78 formed with emphasis on the function of the radial nerve. Any

Figure 1 Anatomy of the humerus. (A) Posterior view of the neural anatomy of the brachium with reference measurements (in cm) from
prominent anatomic landmarks. The area between the axillary nerve and the spiral groove is the proximal safe zone of the posterior humerus.
The distal safe zone is distal to the spiral groove. (B) Anterior view of the shoulder. Note the relationship of the axillary nerve and the an-
terior circumflex humeral artery to the inferior margin of the subscapularis muscle. During the deltopectoral approach, the “three sisters”
(anterior humeral circumflex artery and its 2 venous comitantes) are often ligated separately to minimize blood loss and gain adequate ex-
posure of the humeral metaphysis. (Reproduced with permission from Zlotolow DA, Catalano LW, Barron OA, Glickel SZ. Surgical exposures
of the humerus. J Am Acad Orthop Surg 2006;14:754-765.)
Humeral shaft fractures e89

Figure 2 Arbeitsgemeinschaft für Osteosynthesefragen (AO)/Orthopaedic Trauma Association (OTA) classification of diaphyseal
fractures. (Reproduced with permission from AO Surgery Reference, www.aosurgery.org. Copyright by AO Foundation, Switzerland.)

neurovascular deficit should be noted before any form of treat- subdivided by pattern. A moderate interobserver and sub-
ment is attempted, whether closed reduction, splinting, casting, stantial intraobserver agreement has been shown between
or surgical, and after treatment. Moreover, any concomitant different orthopedic surgeons when humeral shaft fractures
shoulder, elbow, or forearm injury should be taken into con- are classified (Fig. 2).37
sideration because it may guide the treatment plan. Polytrauma Two classification systems are commonly used for shoul-
patients often require surgical fixation to expedite mobilization. der arthroplasty periprosthetic fractures of the humeral shaft.
The first is the Wright and Cofield classification system, which
is based on the location of the fracture in relation to the tip
Classification of the humeral stem.74 Type A begins at the tip of the stem
and extends proximally, type B begins at the tip of the stem
The widely accepted classification for humeral shaft frac- and extends distally, and type C is completely distal to the
tures is the Orthopaedic Trauma Association (OTA)/ tip of the stem. The other classification system, described by
Arbeitsgemeinschaft für Osteosynthesefragen (AO) combined Campbell et al5 and Williams and Iannotti,73 is based on the
classification, derived from the Müller AO long-bone frac- location at which the fracture occurs within the humerus.5,73
tures classification.38 The 3 main types are divided into simple, Region 1 is the tuberosity, region 2 is metaphyseal, region 3
wedge, and complex fractures, which are then further is the proximal humeral diaphysis, and region 4 is the middle
e90 G.F. Updegrove et al.

performed using shoulder spica casts, hanging arm casts,

Thomas arm splints, modified Velpeau dressings, and coap-
tation splints. Although these methods were relatively efficient
in maintaining bony alignment enough for union to occur, they
included the shoulder, elbow, or both joints. Treatment ulti-
mately resulted in proximal or distal stiffness, or both, along
with difficulties in performing activities of daily living.72
Simultaneously, it was established that treatment of humeral
shaft fractures without the use of a rigid fixation led to bone
healing associated with a larger and stronger callus.59 In this
context, the Sarmiento brace was introduced as a solution to
achieve union while maintaining joint motion. Functional
bracing takes advantage of the incompressible fluid effect of
the soft tissues around the fracture site, which maintains a
tight envelope around the fracture fragments. This enve-
lope, aided by the surrounding muscles action vectors, resists
both angular and rotational deforming forces. Shortening,
however, is more dependent on the fracture pattern and the
Figure 3 The Wright and Cofield classification of periprosthetic extent of the initial soft tissue injury and may not be com-
fractures of the humerus.74 pletely corrected by functional bracing. Strict adherence to
Type A begins at the tip of the stem and extends proximally. Type brace use is required to achieve optimal results.12
B begins at the tip of the stem and extends distally. Type C is com- The treatment of a humeral shaft fracture with function-
pletely distal to the tip of the stem. al bracing is a stepwise process. At injury, the upper extremity
is stabilized with an above elbow hanging cast or a coapta-
and distal humeral diaphysis. Poor interobserver reliability tion splint, spanning from the lateral shoulder, turning 180°
and their inability to guide decision making limits these clas- around the elbow, and ending just distal to the axilla. This
sification systems (Fig. 3).2 immobilization is kept in place for 1 to 2 weeks. On follow-
up, the arm is examined, and a functional brace is applied if
the acute symptoms have subsided and soft tissue condi-
Nonoperative management
tions are permissive. The functional brace is made of 2 plastic
sleeves held together by Velcro (Velcro BVBA, Manchester,
Acceptable parameters and the history behind NH, USA) straps. In its original form, as described by
them Sarmiento et al,61 it spans the arm from 5 cm distal to the ax-
illary crease to 5 cm proximal to the olecranon. Some newer
Most surgeons still consider nonsurgical treatment for humeral designs include a lateral sleeve that goes over the shoulder,
shaft fractures the standard of care. In 1966, Klenerman28 re- the importance of which is not yet well defined. The patient
viewed 32 patients with humeral shaft fractures and noted that can use the Velcro straps to adjust the width of the brace daily
anterior angulation of 20° or varus of 30° were the limits for to accommodate for the gradual decrease in soft tissue swell-
the deformities to become clinically obvious, although without ing and disuse muscle atrophy that may set in during treatment.
any compromise in function. These values continue to be The brace should be kept on, and should only be removed
adopted as the acceptable radiographic parameters for bracing. when bathing, until union, which averages 10 to 12 weeks
Variations include the addition of 30° of acceptable valgus (Fig. 4).51,61,63
deformity, 15° of acceptable rotational deformity, and short-
ening of less than 3 cm.66 However, despite the ongoing use
of these cutoffs, they lack supporting Level I or II evidence. Union rate
Most studies to date have found no well-based correla-
tion between the degree of angular deformity and the functional The results of functional bracing have been generally favor-
outcome. Shields et al66 found no correlation between 0° and able in the literature. In one of the largest case series to date,
18° sagittal plane residual deformity or between 2° and 27° Sarmiento et al63 published the outcomes of 620 patients with
of coronal plane residual deformity and the self-reported func- humeral shaft fractures treated with functional bracing. The
tional outcomes scores. nonunion rate was as low as 2% in closed fractures and
6% in open fractures, 87% had less than 16° of varus
Bracing protocol angulation after bony healing, and only 2% had a varus de-
formity of more than 25°.63 Papasoulis et al48 reviewed the
Before 1977, when Sarmiento et al61 first described the func- literature in 2010 and found an overall union rate of 94.5%,
tional brace for humeral shaft fractures, immobilization was ranging from 77.4% in 1 study to 100% in 2 other studies.48
Humeral shaft fractures e91

in the time to union (4.8 and 4.9 months) or final range of

motion was found between the 2 groups.

Fracture pattern

A literature review for midshaft humeral fractures revealed

a highest risk of nonunion for the transverse fractures (OTA/
AO type A3).15,30,63 Ring et al53 reported the highest nonunion
rate among oblique/spiral fractures, but Matsunaga et al39 found
no correlation between fracture type and union rate.
Koch et al30 reviewed 67 humeral shaft fractures treated
with a functional brace. They reported 9 cases of nonunion
in that series, 5 of which were transverse fractures.30 Ekholm
et al15 found nonunion rate of 18% in type A fractures com-
pared with 4% in type B and 0% in type C. Ali et al1 reviewed
138 humeral shaft fractures treated with bracing. The overall
union rate was of 83%. They also reported a trend for prox-
imal third fractures with an oblique to have higher nonunion
rates than other types and location. Comminuted fractures had
an overall higher union rate (89%) irrespective of location.1
Ring et al53 reviewed nonunion cases that were treated with
Figure 4 An over-the-shoulder brace for a humeral fracture. bracing and found that the fractures that were prone to non-
union were the proximal and middle third fractures as opposed
to the distal third fractures and oblique/spiral fractures as
Functional outcome
opposed to transverse fractures. The later finding is the op-
posite of what others have found, possibly because of the small
This high union rate should additionally be coupled with a sample size of 32 in their series.15,30,53,63 In the Matsunaga ran-
similarly high functional outcome, not inferior to that of op- domized controlled trial, no differences were found for the
erative treatment, to validate conservative management as the type or location of the fractures in subgroup analysis in the
treatment of choice in humeral shaft fractures. Many rela- union rate between surgical and nonsurgical groups.39 As for
tively recent studies have addressed this aspect. Shields et al65 healing time after functional bracing, Sarmiento et al63 found
found no statistically significant difference between the op- a median of 12 weeks for transverse fractures, 10 weeks for
erative and nonoperative patients in patient-reported functional oblique fractures, 11 weeks for comminuted fractures, and
outcome scores. Likewise, Koch et al30 found a 95% healing 12 weeks for segmental fractures.
rate among 67 fractures treated with bracing. Three patients The reason different fracture patterns have varying union
had slight limitation in the range of motion, which did not rates is uncertain.1 Transverse fracture patterns might be more
translate to functional impairment, because all 3 were fully prone to nonunion than oblique/spiral patterns, due to less
functional at their jobs.30 bone contact area. In contrast, muscle and soft tissue invagi-
The first randomized controlled study comparing surgi- nation into the fracture site in oblique/spiral fractures could
cal treatment vs. functional bracing for humeral shaft fractures be the cause of nonunion in these fractures compared with
was reported by Matsunaga et al. 39 Surgery consisted of min- transverse fractures.53
imally invasive bridge plating through anterior incisions. The
nonunion rates were 0% for the surgical group and 15% for
the conservative group. The surgical group had a higher Dis- Fracture location
abilities of the Arm, Shoulder and Hand score only at 6
months, with a 6-point difference, whereas a 10-point score Proximal third fractures
difference is needed to be considered clinically important. Oth-
erwise, there were no differences in the Short Form-36, the Fractures of the proximal third of the humeral shaft are no-
visual analog scale score, or the Constant-Murley score.39 torious for having higher nonunion rates than the distal two-
In one of the largest sample studies, Denard et al12 com- thirds, as evidenced by many studies.1,58,69 Ali et al1 reviewed
pared 150 patients treated operatively with 63 patients treated 138 humeral shaft fractures treated with bracing, and the overall
nonoperatively. The rate of nonunion was 20.6% in the union rate was 83%. Subgroup analysis showed lower union
nonoperative group and 8.7% in the surgical group, with a rate in the proximal third fractures (76%) than in middle (88%)
malunion rate of 12.7% vs. 1.3%, respectively. Radial nerve and distal third (85%) fractures. They also reported a trend
palsy occurred in 9.5% of the nonoperatively managed pa- for oblique pattern proximal third fractures to have a higher
tients but in only 2.7% of the surgical patients. No difference nonunion rate than other types and location.1 Rutgers et al58
e92 G.F. Updegrove et al.

reviewed 49 patients treated conservatively by a single surgeon. Holstein-Lewis

The proximal third fracture had a nonunion rate of 29% com-
pared with 4% in the middle third and 0% in the distal third; The Holstein-Lewis fracture is a displaced spiral fracture of
however, these difference did not reach clinical significant the distal humeral shaft, with proximal and radial displace-
because of the small sample size.58 Toivanen et al69 had an ment of the distal fragment, that could potentially injure the
even higher proximal third nonunion rate of 54% (7 of 13). radial nerve as it passes the lateral intramuscular septum. When
A speculated cause of the higher proximal third non- first described in 1966, it was postulated that primary open
union rate is the pull of the deltoid and the pectoralis major reduction and internal fixation is the treatment of choice and
along with muscle interposition at the fracture site.58 that closed reduction is contraindicated.25
However, with time it has become clearer that even the
Holstein-Lewis fractures can be managed conservatively
Distal third fractures without added risk. A review of the Stockholm registry of 361
patients with humeral shaft fractures showed the incidence
Distal third humeral fractures differ from the proximal two- of a Holstein-Lewis fracture was 7.5%. Patients tended to be
thirds in that many surgeons are hesitant about conservative younger and had sustained high-energy trauma. Radial nerve
treatment. Surgical advocates claim that these fractures are palsy was present in 22% (6 of 27) of these patients and in
at high risk of varus malalignment and, when treated con- 8% (27 of 344) in the non-Holstein-Lewis humeral shaft frac-
servatively, are at risk for iatrogenic radial nerve injury during tures types. Among the patients with a Holstein-Lewis fracture,
reduction in a brace. In addition, these fractures will result 26% were treated surgically and 74% were treated conser-
in difficulties with daily living and stiffness at the level of vatively. The fractures of all conservatively treated patient went
the elbow, with ongoing pain until union. Those who rec- into union. All 6 patients with associated radial nerve palsy
ommend bracing for these fractures are supported by the lack recovered; of whom, 2 were treated nonoperatively and four
of evidence favoring surgical treatment and by similar func- surgically.
tional outcomes.54 At a mean follow-up of 6.3 years, there were no differ-
Sarmiento et al60 assessed the results of distal third humeral ences between the operative and the nonoperative groups in
fractures treated with bracing. The union rate was of 96%. functional outcome and range of motion, notably at the elbow.
Varus angulation averaged 9° in 81%, and only 3% had a valgus These results thus refuted the concept that a Holstein-Lewis
deformity. Posterior angulation was present in 39% of the pa- fracture is an absolute indication for surgery, regardless of
tients, ranging from 3° to 22°, and anterior angulation was presence of radial nerve palsy.14
found in 41% of the patients, ranging from 1° to 30°. However,
these deformities did not translate into functional impair- Other factors
ment in this group. Forty-five percent of patients lost between
5° and 45° of shoulder external rotation. Elbow flexion loss Neuhaus et al43 reviewed 79 patients with AO/OTA type A2
was between 5° and 25° in 26%, and elbow extension loss and A3 middle humeral fractures. The union rate of the group
was between 5° and 25° in 24%.60 In the Ekholm et al15 series, was 80%. They analyzed the factors that increased the risk
nonunion after bracing occurred at a rate of 7% for proximal of fracture mobility at 6 weeks of functional bracing. They
third fractures, 17% for middle third fractures, and only 5% found that smoking increased the risk by 6 times, female sex
for distal third fractures. When only type A fractures were by 5 times, and each mm of gap at the fracture site on initial
selected, nonunion rates were of 20% in the proximal third, radiographs by 40%. Angular deformities did not correlate
19% in the middle third, and 13% in the distal third. with fracture mobility (Table I).43
Jawa et al26 reviewed 51 patients with distal third frac-
tures. In the operative group, 14% had new postoperative radial
nerve palsy, whereas no new-onset radial nerve palsy was seen Operative indications
in the bracing group. The average elbow flexion loss was 3°
in the operative group and 6° in the bracing group. This dif- Operative management of humeral shaft fractures may be in-
ference was not significant, and the fractures all of those who dicated in a variety of scenarios. Operative stabilization should
were braced healed. They concluded that operative treat- be used when an acceptable alignment cannot be achieved
ment is more predictable in malalignment outcome, which
may not be clinically important.26 In another study dealing
Table I Patient and fracture characteristics more prone to
with distal third fractures, Pehlivan et al51 reviewed 21 iso-
nonunion
lated closed distal third humeral fractures treated with
functional bracing. The union rate was 100% at an average Proximal third fractures
of 12 weeks. The average varus angulation was 8° in 8 pa- Oblique pattern in the proximal third
Smoking
tients. Shortening averaged 10 mm in 10 patients. No clinically
Female sex
significant range of motion loss was found at a mean follow-
Gap size at the fracture site
up of 39 months.51
Humeral shaft fractures e93

in a brace. With cases of open fractures associated with severe

Table II Indication for operative management of humeral shaft
soft tissue injury or high-velocity gunshot injuries, often an fractures
operative débridement is performed, and fixation may also
Indications Relative indications
be performed while the fracture is exposed. In low-velocity
gunshot injuries, however, the type of management is dic- Acceptable alignment cannot Low velocity gunshot injury
tated by the fracture characteristics, and even when the fracture be achieved with brace Polytrauma
is associated with radial nerve palsy, conservative treatment Skin condition precludes Bilateral humerus fractures
bracing (burns, etc.) Open fractures
is still an option.63 Given the high rate of spontaneous re-
High-velocity gunshot injury Comminuted fractures
covery of radial nerve palsy in closed humeral shaft fractures,
Open fractures with severe soft Segmental fractures
early nerve exploration and fracture fixation is not indi- tissue injury
cated. However, early nerve exploration with osteosynthesis Vascular injury requiring repair
is agreed upon when one of the following factors is present: Brachial plexus injury
open fracture, vascular injury, high-velocity gunshot injury, Pathologic fractures
severe soft tissue injury, or manipulation induced secondary Radial nerve injury after
radial nerve injury.3,31,45,52,55 A vascular injury requiring repair manipulation
is an absolute indication for operative management, because Intra-articular fractures
rigid fixation protects the vascular anastomosis.50 Floating elbow
Brachial plexus injuries are considered an indication for
operative management, because a nonstable fracture delays
rehabilitation and bracing carries a high nonunion rate (45%).4 the muscle belly on the anterior aspect of the humerus,
A pathologic fracture is also in an indication for surgical exploiting the dual innervation of this muscle. The lateral
treatment.42 Comminuted and segmental fractures have a po- antebrachial nerve must be protected distally as it exits
tential for healing with bracing and thus can only be considered between the biceps and brachialis, as well as the radial
as a relative indication for operative management.60 Al- nerve between the brachialis and brachioradialis. This ap-
though bilateral humeral fractures have been considered an proach allows for excellent exposure of the proximal and
absolute indication for surgery, bracing is still possible if the middle humeral shaft.
patient is ambulatory and is able to perform activities of daily For distal fractures, a posterior approach may be more ad-
living while wearing the brace.62,76 Polytrauma is a relative vantageous to expose both the shaft and the elbow. Posterior
indication for fixation, because this potentially allows for im- exposure also allows the radial nerve to be visualized prox-
proved mobility of these patients by use of their upper limb. imally, providing the ability to place hardware underneath the
Immediate weight bearing has been shown to be safe without nerve at the spiral groove if proximal fixation is required. There
an increased rate of nonunion or malunion after plate fixa- are several deep exposures with a posterior approach, al-
tion of the humeral shaft.68 though most often it is performed with medial and lateral
Cases in which the humeral shaft fracture also has prox- paratricipital windows or the triceps is split in line with its
imal or distal intra-articular extension and the intra-articular fibers and tendon. The paratricipital windows afford excel-
fracture meets operative indications, the humeral shaft frac- lent exposure of the distal fragment, allow for periarticular
ture is often fixed in the same setting. Similarly, when an fixation of the distal humerus, and are often preferred because
ipsilateral forearm fracture is present, termed a floating- it avoids dissection into the triceps muscle belly. Gerwin et
elbow, fixation of the humeral shaft may also be performed al18 found that 55% of the distal humerus could be visual-
(Table II). ized using a paratricipital exposure without mobilization of
the radial nerve. Reflecting the triceps medially increased the
exposure to 94% of the humerus, providing excellent prox-
Open reduction and internal fixation imal and distal exposure. The radial nerve must be identified
as it exits the spiral groove and pierces the intramuscular
Many consider open reduction and plate fixation as the pre- septum and then mobilized and protected before the triceps
ferred method for operative stabilization of humeral shaft is reflected medially. The triceps-splitting approach is per-
fractures. Among its advantages are the multiple surgical ex- formed between the long and lateral head of the triceps,
posures that can be selected based on surgeon preference as allowing deep exposure to the medial head and humeral shaft.
well as factors such as fracture pattern, soft tissue wounds, This provides direct exposure of the spiral groove, where the
or the need to address the radial nerve. Many of the ap- radial nerve can then be protected. With a triceps-splitting
proaches may also be extended to address concomitant approach, 76% of the humerus could be visualized with radial
fractures around the shoulder and elbow. nerve mobilization.18
The anterolateral exposure is a distal extension of the A variety of options are available when plates are se-
deltopectoral approach along the lateral side of the biceps. lected for fixation. Although large fragment plates, both broad
After the biceps is reflected medially, the deep dissection and narrow, are often used, small fragment plates and some-
splits the brachialis between the middle and lateral thirds of times even minifragment plates may also have a role. Adhering
e94 G.F. Updegrove et al.

to basic AO principles of fracture management is important

when plate fixation is performed. Plates can be used for direct
compression fracture fixation, neutralization of lag screw
interfragmentary fixation, or in a bridging fashion. Direct re-
duction with absolute stability and fixation is ideal when the
morphology of the fracture allows. A variety of reduction tools
and clamps are available to aid with provisional reduction and
stabilization. Smaller bone fragments also may be reduced
and stabilized with small-fragment or minifragment screws.
With significant comminution that is not amendable to direct
reduction, the segment should be bridged. If severe commi-
nution with nonviable fragments or bone loss is present, the
humerus can be shortened to allow bony opposition and
improve healing. This is better tolerated in the upper extrem-
ity then the lower, although some muscle weakness may result
from significant shortening.
Interest in dual plating of humeral shaft fractures has led
to a number of recent biomechanical studies to demonstrate
its effectiveness.27,32,33 Dual plates may be beneficial to improve
stability of the construct and also to assist with provisional
fixation of the reduction. Large-fragment plates, both broad
and narrow, are often used; however, small-fragment plates
can be advantageous, especially for small patients, as well
as dual plating. A finite element study showed that dual plating Figure 5 Humeral shaft fracture treated with minifragment plate
also improves weight-bearing tolerance.32 Immediate weight for provisional fixation with large fragment plate added for stability.
bearing has been shown to be safe after open reduction and
plate fixation.68
Locking screws have proven to be of significant advance- significantly increased the risk of shoulder complications and
ment in plate fixation; however, their use may not be as reoperation.
pronounced in humeral shaft fracture management as it is with A concern with intramedullary nailing is increased shoul-
periarticular fractures. Biomechanical studies in synthetic and der pain and increased reoperation rates.6,36,56,71 Various entry
cadaveric models have shown locking screws do not offer bio- portals have been proposed to address the increased inci-
mechanical benefit in plate fixation of humeral shaft fractures, dence of shoulder pain after antegrade intramedullary nailing
and additional locking screws in osteoporotic bone do not of the humerus, which is thought to occur due to injury to
improve stability (Fig. 5).22,46 the rotator cuff. These include more medial and lateral portals
to avoid the insertion of the rotator cuff tendon as well ac-
cessing the proximal humerus through the rotator interval.8,49
Intramedullary nail fixation This is sometimes performed in conjunction with a biceps
tenodesis, which has also been proposed as a source of pain
Plate fixation does allow for direct reduction and compres- after intramedullary nailing.8 Retrograde intramedullary nailing
sion, but intramedullary fixation has the advantages of of the humerus may also be performed, which avoids injury
providing a load-sharing implant while preserving the peri- to the shoulder altogether. A prospective randomized study
osteal blood supply and minimizing the disruption of the of antegrade compared with retrograde locked nailing of the
biology at the fracture site. Although nonlocked devices, such humerus demonstrated a longer time for return of function
as Kirschner wires, flexible nails, and Enders nails, have largely of the shoulder for antegrade; however, longer return to func-
been abandoned due to their inability to control rotation, there tion of the elbow was noted in the retrograde group.7
remains an interest and use of intramedullary locked devices. A recent systematic review evaluated minimally invasive
Locked intramedullary nails have been shown to have similar plating vs. open reduction and plate fixation or intramedul-
union rates to plate fixation and also similar rates of radial lary nailing of humeral shaft fractures. The study showed that
nerve palsy.19,23,35,36,47,71,77 minimally invasive techniques had better outcomes with lower
Zhao et al77 performed a systematic review of meta- complication rates, although poor reporting of randomiza-
analyses of intramedullary nail fixation compared with plate tion and significant bias in the primary studies may limit the
fixation for humeral shaft fractures. The review included 7 significance of this conclusion.24
meta-analyses of randomized controlled trials. Their results A review of the American Board of Orthopaedic Surgery
analysis found no difference in the rate of union, radial nerve case database demonstrated a decline in the use of intramed-
injury, or infection. Intramedullary nail use, however, ullary nails for treatment of humeral shaft fractures from 2004
Humeral shaft fractures e95

to 2013.19 However, this study also demonstrated decreased

complications in the intramedullary nail groups and no sig-
nificant difference in nonunion rate.

External fixation

External fixation remains an important option to consider in

certain situations such as polytrauma patients, bilateral frac-
tures, and severe fracture comminution or soft tissue injury.
It is important to be aware of the neurovascular structures at
risk, most notably the radial nerve, during pin insertion in
the humerus. There are multiple described techniques avail-
able for review of safe placement of pins in the upper
extremity.17,57 Direct visualization of the radial nerve during
distal pin placement is recommended. Scaglione et al64 ret-
rospectively reviewed 85 shaft or extra-articular distal third
humeral fractures treated definitively with eternal fixation. They
reported a healing rate of 97.6% at an average of 12 weeks.
There were no iatrogenic radial nerve injuries from pin place-
ment, although there was 1 case of neurapraxia, which
resolved. Complications included 1 delayed union, 1 refrac-
ture, and 5 that healed with residual angular deformity.
Figure 6 Humeral fracture at the tip of the arthroplasty stem
Periprosthetic fractures managed with hybrid screw and cable fixation to a plate.

Periprosthetic fractures in the humerus remain a challeng-

ing problem. Current evidence on treatment and outcome of fixation is often the preferred method, although intramedul-
these fractures is limited, although as rates of shoulder ar- lary fixation and even external fixation may prove
throplasty rise, the incidence of periprosthetic fractures is advantageous in certain scenarios.
expected to rise as well.10 The goals of treatment are to achieve
fracture union while maintaining the stability of the prosthe-
sis, preserve the glenohumeral motion, and restore shoulder
Disclaimer
function. Decision making should be based on the location
of the fracture, the timing of the fracture, and the stability Joseph A. Abboud receives research support from DePuy,
of the components. 20 Treatment strategies vary from Zimmer, Tornier, Integra, OREF, DJO, and Orthospace;
nonoperative management, to open reduction and internal fix- is a paid consultant for Tornier, Cayenne, DJO, and Globus;
ation, to revision arthroplasty.2,16,34,41 Indications for treatment receives royalties from Integra, Wolters Kluwer Health–
mirror those of humeral shaft fractures without a prosthe- Lippincott Williams & Wilkins, Cayenne, and DJO; receives
sis. Nonoperative management can be attempted if the stock options from and is on the Scientific Advisory Board
prosthesis is stable and acceptable alignment can be achieved of MinInvasive; receives stock options from Aevumed; and
with functional bracing.44 An unstable prosthesis should be is on the Board of Directors of MASES.
revised, often with a longer stem, and with consideration of The other authors, their immediate families, and any
cortical strut allograft or additional fixation, depending on bone research foundations with which they are affiliated have
quality (Fig. 6).11 not received any financial payments or other benefits from
any commercial entity related to the subject of this article.
Summary

Humeral shaft fractures can often be successfully managed

nonoperatively with splints and bracing. Radial nerve inju- References
ries are not uncommon, both from the injury as well as
iatrogenic injuries from the treatment. Acceptable radio- 1. Ali E, Griffiths D, Obi N, Tytherleigh-Strong G, Van Rensburg L.
graphic parameters are not well supported and do not seem Nonoperative treatment of humeral shaft fractures revisited. J Shoulder
Elbow Surg 2015;24:210-4. http://dx.doi.org/10.1016/j.jse.2014.05.009
to correlate with functional outcome. In certain cases, a more 2. Andersen JR, Williams CD, Cain R, Mighell M, Frankle M. Surgically
predictable result for alignment and union may be achieved treated humeral shaft fractures following shoulder arthroplasty. J Bone
with operative intervention. Open reduction and plate Joint Surg Am 2013;95:9-18. http://dx.doi.org/10.2106/JBJS.K.00863
e96 G.F. Updegrove et al.

3. Bishop J, Ring D. Management of radial nerve palsy associated with 21. Guse TR, Ostrum RF. The surgical anatomy of the radial nerve around
humeral shaft fracture: a decision analysis model. J Hand Surg Am the humerus. Clin Orthop Relat Res 1995;(320):149-53.
2009;34:991-6, e1. http://dx.doi.org/10.1016/j.jhsa.2008.12.029 22. Hak DJ, Althausen P, Hazelwood SJ. Locked plate fixation of
4. Brien WW, Gellman H, Becker V, Garland DE, Waters RL, Wiss DA. osteoporotic humeral shaft fractures: are two locking screws per segment
Management of fractures of the humerus in patients who have an injury enough? J Orthop Trauma 2010;24:207-11. http://dx.doi.org/10
of the ipsilateral brachial plexus. J Bone Joint Surg 1990;72:1208- .1097/BOT.0b013e3181bdd1da
10. 23. Hashib G. Management of humeral shaft fracture: a comparative study
5. Campbell JT, Moore RS, Iannotti JP, Norris TR, Williams GR. between interlocking nail and dynamic compression plating. Int J Res
Periprosthetic humeral fractures: mechanisms of fracture and treatment Orthop 2016;2:40-7. http://dx.doi.org/10.18203/issn.2455-4510
options. J Shoulder Elbow Surg 1998;7:406-13. .IntJResOrthop20161457
6. Changulani M, Jain UK, Keswani T. Comparison of the use of the 24. Hohmann E, Glatt V, Tetsworth K. Minimally invasive plating versus
humerus intramedullary nail and dynamic compression plate for the either open reduction and plate fixation or intramedullary nailing of
management of diaphyseal fractures of the humerus. A randomised humeral shaft fractures: a systematic review and meta-analysis of
controlled study. Int Orthop 2006;31:391-5. http://dx.doi.org/10.1007/ randomized controlled trials. J Shoulder Elbow Surg 2016;25:1634-42.
s00264-006-0200-1 http://dx.doi.org/10.1016/j.jse.2016.05.014
7. Cheng HR, Lin J. Prospective randomized comparative study of antegrade 25. Holstein A, Lewis GF. Fractures of the humerus with radial-nerve
and retrograde locked nailing for middle humeral shaft fracture. J Trauma paralysis. J Bone Joint Surg Am 1963;45:1382-8.
2008;65:94-102. http://dx.doi.org/10.1097/TA.0b013e31812eed7f 26. Jawa A, McCarty P, Doornberg J, Harris M, Ring D. Extra-articular
8. Christ AB, Gausden EB, Warner SJ, Nellestein AM, Thacher R, distal-third diaphyseal fractures of the humerus. A comparison of
Lorich DG. Rotator cuff-sparing approach for antegrade humeral functional bracing and plate fixation. J Bone Joint Surg Am
nailing with biceps tenodesis: a technical trick with clinical implications. 2006;88:2343-7. http://dx.doi.org/10.2106/JBJS.F.00334
J Orthop Trauma 2016;31:e60-5. http://dx.doi.org/10.1097/BOT 27. Karakasli A, Basci O, Ertem F, Sekik E, Havitcioglu H. Dual plating
.0000000000000684 for fixation of humeral shaft fractures: a mechanical comparison of
9. Court-Brown CM, Caesar B. Epidemiology of adult fractures: a review. various combinations of plate lengths. Acta Orthop Traumatol Turc
Injury 2006;37:691-7. http://dx.doi.org/10.1016/j.injury.2006.04.130 2016;50:432-6. http://dx.doi.org/10.1016/j.aott.2016.07.002
10. Day JS, Lau E, Ong KL, Williams GR, Ramsey ML, Kurtz SM. 28. Klenerman L. Fractures of the shaft of the humerus. J Bone Joint Surg
Prevalence and projections of total shoulder and elbow arthroplasty in Br 1966;48:105-11.
the United States to 2015. J Shoulder Elbow Surg 2010;19:1115-20. 29. Klepps S, Auerbach J, Calhon O, Lin J, Cleeman E, Flatow E. A
http://dx.doi.org/10.1016/j.jse.2010.02.009 cadaveric study on the anatomy of the deltoid insertion and its
11. Dehghan N, Chehade M, McKee MD. Current perspectives in the relationship to the deltopectoral approach to the proximal humerus. J
treatment of periprosthetic upper extremity fractures. J Orthop Shoulder Elbow Surg 2004;13:322-7. http://dx.doi.org/10.1016/
Trauma 2011;25(Suppl 2):S71-6. http://dx.doi.org/10.1097/BOT j.jse.2003.12.014
.0b013e31821acfa5 30. Koch PP, Gross DF, Gerber C. The results of functional (Sarmiento)
12. Denard A, Richards JE, Obremskey WT, Tucker MC, Floyd M, Herzog bracing of humeral shaft fractures. J Shoulder Elbow Surg 2002;11:143-
GA. Outcome of nonoperative vs operative treatment of humeral shaft 50. http://dx.doi.org/10.1067/mse.2002.121634
fractures: a retrospective study of 213 patients. Orthopedics 2010;33. 31. Korompilias AV, Lykissas MG, Kostas-Agnantis IP, Vekris MD,
http://dx.doi.org/10.3928/01477447-20100625-16 Soucacos PN, Beris AE. Approach to radial nerve palsy caused by
13. Ekholm R, Adami J, Tidermark J, Hansson K, Törnkvist H, Ponzer S. humerus shaft fracture: is primary exploration necessary? Injury
Fractures of the shaft of the humerus. An epidemiological study of 401 2013;44:323-6. http://dx.doi.org/10.1016/j.injury.2013.01.004
fractures. J Bone Joint Surg Br 2006;88:1469-73. http://dx.doi.org/ 32. Kosmopoulos V, Luedke C, Nana AD. Dual small fragment plating
10.1302/0301-620X.88B11.17634 improves screw-to-screw load sharing for mid-diaphyseal humeral
14. Ekholm R, Ponzer S, Törnkvist H, Adami J, Tidermark J. The Holstein- fracture fixation: a finite element study. Technol Health Care 2015;23:83-
Lewis humeral shaft fracture: aspects of radial nerve injury, primary 92. http://dx.doi.org/10.3233/THC-140875
treatment, and outcome. J Orthop Trauma 2008;22:693-7. http://dx. 33. Kosmopoulos V, Nana AD. Dual plating of humeral shaft fractures:
doi.org/10.1097/BOT.0b013e31818915bf orthogonal plates biomechanically outperform side-by-side plates. Clin
15. Ekholm R, Tidermark J, Törnkvist H, Adami J, Ponzer S. Outcome after Orthop Relat Res 2013;472:1310-7. http://dx.doi.org/10.1007/
closed functional treatment of humeral shaft fractures. J Orthop Trauma s11999-013-3379-7
2006;20:591-6. http://dx.doi.org/10.1097/01.bot.0000246466.01287 34. Kurowicki J, Momoh E, Levy JC. Treatment of periprosthetic humerus
.04 fractures with open reduction and internal fixation. J Orthop Trauma
16. García-Fernández C, Lópiz-Morales Y, Rodríguez A, López-Durán L, 2016;30:e369-74. http://dx.doi.org/10.1097/BOT.0000000000000646
Martínez FM. Periprosthetic humeral fractures associated with reverse 35. Kurup H, Hossain M, Andrew JG. Dynamic compression plating versus
total shoulder arthroplasty: incidence and management. Int Orthop locked intramedullary nailing for humeral shaft fractures in adults.
2015;39:1965-9. http://dx.doi.org/10.1007/s00264-015-2972-7 Cochrane Database Syst Rev 2011;(6):CD005959. http://dx.doi.org/10
17. Gausepohl T, Koebke J, Pennig D, Hobrecker S, Mader K. The .1002/14651858.CD005959.pub2
anatomical base of unilateral external fixation in the upper limb. Injury 36. Ma J, Xing D, Ma X, Gao F, Wei Q, Jia H, et al. Intramedullary nail
2000;31(Suppl 1):11-20. versus dynamic compression plate fixation in treating humeral shaft
18. Gerwin M, Hotchkiss RN, Weiland AJ. Alternative operative exposures fractures: grading the evidence through a meta-analysis. PLoS One
of the posterior aspect of the humeral diaphysis with reference to the 2013;8:e82075. http://dx.doi.org/10.1371/journal.pone.0082075
radial nerve. J Bone Joint Surg Am 1996;78:1690-5. 37. Mahabier KC, Van Lieshout EM, Van Der Schaaf BC, Roukema GR,
19. Gottschalk MB, Carpenter W, Hiza E, Reisman W, Roberson J. Humeral Punt BJ, Verhofstad MH, et al. Reliability and reproducibility of the
shaft fracture fixation: incidence rates and complications as reported by OTA/AO classification for humeral shaft fractures. J Orthop Trauma
American Board of Orthopaedic Surgery Part II Candidates. J Bone Joint 2017;31:e75-80. http://dx.doi.org/10.1097/BOT.0000000000000738
Surg Am 2016;98:e71. http://dx.doi.org/10.2106/JBJS.15.01049 38. Marsh JL, Slongo TF, Agel J, Broderick JS, Creevey W, DeCoster TA,
20. Gregory JM, Hsu J, Galatz LM. Periprosthetic humeral fractures et al. Fracture and dislocation classification compendium—2007:
in shoulder arthroplasty. Semin Arthroplasty 2014;25:59-63. Orthopaedic Trauma Association classification, database and outcomes
http://dx.doi.org/10.1053/j.sart.2014.02.009 committee. J Orthop Trauma 2007;21(10 Suppl):S1-6.
Humeral shaft fractures e97

39. Matsunaga FT, Tamaoki MJ, Matsumoto MH, Netto NA, Faloppa F, 58. Rutgers M, Ring D. Treatment of diaphyseal fractures of the humerus
Belloti JC. Minimally invasive osteosynthesis with a bridge plate versus using a functional brace. J Orthop Trauma 2006;20:597-601.
a functional brace for humeral shaft fractures: a randomized controlled http://dx.doi.org/10.1097/01.bot.0000249423.48074.82
trial. J Bone Joint Surg Am 2017;99:583-92. http://dx.doi.org/10.2106/ 59. Rüedi T, Moshfegh A, Pfeiffer KM, Allgöwer M. Fresh fractures of the
JBJS.16.00628 shaft of the humerus—conservative or operative treatment? Reconstr Surg
40. McCann PA, Smith GC, Clark D, Amirfeyz R. The tricipital Traumatol 1974;14:65-74.
aponeurosis—a reliable soft tissue landmark for humeral plating. Hand 60. Sarmiento A, Horowitch A, Aboulafia A, Vangsness CT. Functional
Surg 2015;20:53-8. http://dx.doi.org/10.1142/S0218810415500070 bracing for comminuted extra-articular fractures of the distal third of
41. Mineo GV, Accetta R, Franceschini M, Pedrotti Dell’Acqua G, Calori the humerus. J Bone Joint Surg Br 1990;72:283-7.
GM, Meersseman A. Management of shoulder periprosthetic fractures: 61. Sarmiento A, Kinman PB, Galvin EG, Schmitt RH, Phillips JG.
our institutional experience and review of the literature. Injury Functional bracing of fractures of the shaft of the humerus. J Bone Joint
2013;44(Suppl 1):S82-5. http://dx.doi.org/10.1016/S0020-1383 Surg Am 1977;59:596-601.
(13)70018-4 62. Sarmiento A, Latta LL. Fractures of the humeral diaphysis. In: Functional
42. Muramatsu K, Ihara K, Iwanagaa R, Taguchi T. Treatment of metastatic fracture bracing: tibia, humerus, and ulna. Heidelberg: Springer; 1995.
bone lesions in the upper extremity: indications for surgery. Orthopedics p. 141-203.
2010;33:807. 63. Sarmiento A, Zagorski JB, Zych GA, Latta LL, Capps CA. Functional
43. Neuhaus V, Menendez M, Kurylo JC, Dyer GS, Jawa A, Ring D. Risk bracing for the treatment of fractures of the humeral diaphysis. J Bone
factors for fracture mobility six weeks after initiation of brace treatment Joint Surg Am 2000;82:478-86.
of mid-diaphyseal humeral fractures. J Bone Joint Surg Am 64. Scaglione M, Fabbri L, Dell’Omo D, Goffi A, Guido G. The
2014;96:403-7. http://dx.doi.org/10.2106/JBJS.M.00089 role of external fixation in the treatment of humeral shaft
44. Neviaser AS, Flatow EL. Periprosthetic humeral fractures: you’re fractures: a retrospective case study review on 85 humeral
breakin’ my heart. Semin Arthroplasty 2011;22:48-50. http://dx.doi fractures. Injury 2015;46:265-9. http://dx.doi.org/10.1016/j.injury
.org/10.1053/j.sart.2011.01.012 .2014.08.045
45. Niver GE, Ilyas AM. Management of radial nerve palsy following 65. Shields E, Sundem L, Childs S, Maceroli M, Humphrey C, Ketz J, et al.
fractures of the humerus. Orthop Clin North Am 2013;44:419-24, x. Factors predicting patient-reported functional outcome scores after
http://dx.doi.org/10.1016/j.ocl.2013.03.012 humeral shaft fractures. Injury 2015;46:693-8. http://dx.doi.org/10.1016/
46. O’Toole RV, Andersen RC, Vesnovsky O, Alexander M, Topoleski LD, j.injury.2015.01.027
Nascone JW, et al. Are locking screws advantageous with plate fixation 66. Shields E, Sundem L, Childs S, Maceroli M, Humphrey C, Ketz JP,
of humeral shaft fractures? A biomechanical analysis of synthetic and et al. The impact of residual angulation on patient reported functional
cadaveric bone. J Orthop Trauma 2008;22:709-15. http://dx.doi.org/10 outcome scores after non-operative treatment for humeral shaft fractures.
.1097/BOT.0b013e31818df8cb Injury 2015;47:1-5. http://dx.doi.org/10.1016/j.injury.2015.12.014
47. Ouyang H, Xiong J, Xiang P, Cui Z, Chen L, Yu B. Plate versus 67. Lambert SM. Shoulder girdle and arm. In: Standing S, editor.
intramedullary nail fixation in the treatment of humeral shaft fractures: Gray’s anatomy. New York: Elsevier Limited; 2016. p. 797-
an updated meta-analysis. J Shoulder Elbow Surg 2013;22:387-95. 836.e1.
http://dx.doi.org/10.1016/j.jse.2012.06.007 68. Tingstad EM, Wolinsky PR, Shyr Y, Johnson KD. Effect of immediate
48. Papasoulis E, Drosos GI, Ververidis AN, Verettas DA. Functional bracing weightbearing on plated fractures of the humeral shaft. J Trauma
of humeral shaft fractures. A review of clinical studies. Injury 2000;49:278-80.
2010;41:e21-7. http://dx.doi.org/10.1016/j.injury.2009.05.004 69. Toivanen JA, Nieminen J, Laine HJ, Honkonen SE, Järvinen MJ.
49. Park JY, Pandher DS, Chun JY, Lee ST. Antegrade humeral nailing Functional treatment of closed humeral shaft fractures. Int Orthop
through the rotator cuff interval: a new entry portal. J Orthop Trauma 2005;29:10-3. http://dx.doi.org/10.1007/s00264-004-0612-8
2008;22:419-25. http://dx.doi.org/10.1097/BOT.0b013e318173f751 70. Volgas DA, Stannard JP, Alonso JE. Nonunions of the humerus. Clin
50. Paryavi E, Pensy RA, Higgins TF, Chia B, Eglseder WA. Salvage of Orthop Relat Res 2004;419:46-50.
upper extremities with humeral fracture and associated brachial artery 71. Wali MG, Baba AN, Latoo IA, Bhat NA, Baba OK, Sharma S. Internal
injury. Injury 2014;45:1870-5. http://dx.doi.org/10.1016/j.injury fixation of shaft humerus fractures by dynamic compression plate or
.2014.08.038 interlocking intramedullary nail: a prospective, randomised study.
51. Pehlivan O. Functional treatment of the distal third humeral shaft Strategies Trauma Limb Reconstr 2014;9:133-40. http://dx.doi.org/
fractures. Arch Orthop Trauma Surg 2002;122:390-5. http://dx.doi.org/ 10.1007/s11751-014-0204-0
10.1007/s00402-002-0403-x 72. Walker M, Palumbo B, Badman B, Brooks J, Van Gelderen J, Mighell
52. Prodromo J, Goitz RJ. Management of radial nerve palsy associated with M. Humeral shaft fractures: a review. J Shoulder Elbow Surg
humerus fracture. J Hand Surg Am 2013;38:995-8, quiz 998. 2011;20:833-44. http://dx.doi.org/10.1016/j.jse.2010.11.030
http://dx.doi.org/10.1016/j.jhsa.2013.02.003 73. Williams GR, Iannotti JP. Management of periprosthetic fractures: the
53. Ring D, Chin K, Taghinia AH, Jupiter JB. Nonunion after functional shoulder. J Arthroplasty 2002;17(4 Suppl 1):14-6. http://dx.doi.org/10
brace treatment of diaphyseal humerus fractures. J Trauma .1054/arth.2002.32683
2007;62:1157-8. http://dx.doi.org/10.1097/01.ta.0000222719.52619.2c 74. Wright TW, Cofield RH. Humeral fractures after shoulder arthroplasty.
54. Ring D, Jawa A, Cannada L. Clinical faceoff: are distal-third diaphyseal J Bone Joint Surg Am 1995;77:1340-6.
humerus fractures best treated nonoperatively? Clin Orthop Relat Res 75. Xue Z, Ding H, Hu C, Xu H, An Z. An anatomical study of the nutrient
2016;474:310-4. http://dx.doi.org/10.1007/s11999-015-4636-8 foramina of the human humeral diaphysis. Med Sci Monit
55. Rocchi M, Tarallo L, Mugnai R, Adani R. Humerus shaft fracture 2016;22:1637-45. http://dx.doi.org/10.12659/msm.898361
complicated by radial nerve palsy: is surgical exploration necessary? 76. Zafar MS, Porter K. Humeral shaft fractures: a review of literature.
Musculoskelet Surg 2016;100(Suppl 1):53-60. http://dx.doi.org/10.1007/ Trauma 2016;9:273-82. http://dx.doi.org/10.1177/1460408607088315
s12306-016-0414-3 77. Zhao JG, Wang J, Wang C, Kan SL. Intramedullary nail versus plate
56. Rommens PM, Kuechle R, Bord T, Lewens T, Engelmann R, Blum J. fixation for humeral shaft fractures. Medicine (Baltimore) 2015;94:e599.
Humeral nailing revisited. Injury 2008;39:1319-28. http://dx.doi http://dx.doi.org/10.1097/MD.0000000000000599
.org/10.1016/j.injury.2008.01.014 78. Zlotolow DA, Catalano LW, Barron OA, Glickel SZ. Surgical exposures
57. Ruland WO. Is there a place for external fixation in humeral shaft of the humerus. J Am Acad Orthop Surg 2006;14:754-65.
fractures? Injury 2000;31(Suppl 1):27-34. http://dx.doi.org/10.5435/00124635-200612000-00007