Humeral Shaft Fracture

Nonoperative Management




< 20o sagittal

< 30o coronal

< 3 cm of shortening


Undisplaced Humeral Fracture APUndisplaced Humeral Fracture Lateral




1.  Vietnam Cast / hanging cast


2.  Functional bracing / Sarmiento


Functional Humerus Brace




Union rates


Denard et al Orthopedics 2010

- non operative v operative treatment 213 fractures

- non operative: 20% nonunion and 12% malunion

- operative group: 8% nonunion and 1% malunion

- no difference in time to union in two groups


Ali et al. J Shoulder and Elbow Surgery 2015

- retrospective review of 138 patients treated nonoperatively

- 17% nonunion (24/138)

- proximal fractures highest nonunion rate


Time to union and functional outcome


Papasoulis et al. Injury 2010

- literature review of functional bracing humerus shaft fractures

- average time to union 10.7 weeks

- full shoulder ROM in 80%

- full elbow ROM in 85%


Humerus shaft 1Humerus shaft 2Humerus shaft 3Humerus shaft 4Humerus shaft 5

Progressive union in midshaft humerus fracture treated nonoperatively


Humerus shaft nonunionHumerus nonunion

Nonunion in a proximal humerus shaft fracture treated nonoperatively


Radial Nerve Injury




Shao et al. JBJS Br 2005

- systematic review of humerus shaft fracture

- 11.8% (532/4517) radial nerve injuries

- most common with middle, and middle/distal fractures

- 70% spontaneously recovered without intervention

- recovery rate 88% in those undergoing delayed exporation (14 weeks)

- recovery rate 88% in those undergoing immediate exploration


Holstein Lewis fracture


Holstein LewisHolstein Lewis fracture


Holstein-Lewis JBJS Am 1963

- series of 7 oblique distal third fractures with radial nerve injury

- all were treated operatively

- nerve in fracture gap in 2 / impaled in 1 / severed in 2 / contused +/- in callus in 2

- advised against attempted closed reduction

- risk of contusing nerve between fragments

- advised early open reduction through anterolateral approach

- the radial nerve is closely assoicated with the fracture site and the fracture spike


Korompilias et al. Injury 2013

- 25 patients with complete nerve palsy and humerus shaft fractures

- 13 fully recovered by 12 weeks

- explored 12 patients with no recovery at 16 weeks

- nerve lacerated in two patients

- intact in remainder - these fully recovered by 20 - 24 weeks




Absolute indications for exploration

- open fractures

- radial nerve palsy following closed reduction



- Holstein-Lewis fracture patterns

- patient undergoing ORIF

- no recovery at 10 - 12 weeks


Expectant management

- wait 10 - 12 weeks

- if no recovery EMG

- consider exploration +/- neurolysis +/- nerve graft at that time

- if that fails, tendon transfer for radial nerve palsy


Operative Management of Humeral Shaft Fractures






Compound fracture

Failure to obtain / maintain acceptable reduction

Radial nerve palsy post reduction

Displaced Holstein Lewis with radial nerve palsy






Floating elbow

Segmental fracture

Proximal fracture

Pathological fracture - won't heal

Bilateral humeral fractures

Obese (very difficult to splint)

Brachial plexus injury - allows early rehab


Humeral Fracture SegmentalDisplaced Humeral Fracture APDisplaced Humeral Fracture Lateral




Open ORIF with plate


Intra-medullary nail




Nail v plate


Beeres et al. Eur J Trauma Emerg Surg 2021

- IM nail v open plate

- meta-analysis of 10 RCTs (500 pts)

- SR of 18 observational studies (4900 pts)

- 17% of IMN required reoperation for shoulder impingement

- IMN had faster union and lower infection rate

- no difference nonunion rates or shoulder function scores


van der Wall et al. Eur J Trauma Emerg Surg 2021

- IM nail v MIPO
- meta-analysis of 2 RCTs (87 pts)

- systematic review of 5 observational studies (600 patients)

- MIPO lower risk of nonunion and re-intervention

- MIPO better shoulder function



Beeres et al. Injury 2021


- meta-analysis of 2 RCTS (98 pts)

- systematic review of 7 observational studies (263 patients)

- MIPO lower risk of nonunion

- no difference in infection or time to union


1.  Open ORIF with plate


Humeral Plate LateralHumeral Plate Long AP




Anterolateral approach - proximal 2/3 of humerus

Posterior approach / triceps split - distal 1/3 of humerus

Posterior approach with triceps flip - Holstein lewis


A.  Anterolateral Approach Humerus for proximal / mishaft fractures


Prox humerus 1Prox humerus 2Prox humerus ORIFProximal humerus ORIF


AO foundation surgical approach


Vumedi video



- proximal fractures

- midshaft fractures


Set up

- lazy beachchair

- flat with arm on arm table

- ensure can get good images of humeral head



- deltopectoral proximally (to coracoid)

- lateral humerus distally

- distally between mobile wad and biceps



- deltopectoral groove

- identify and protect cephalic vein

- take vein laterally to minimis bleeding

- can partially release deltoid insertion if needed



- follow cephalic

- open fascia laterally

- identify plane between biceps and brachialis

- biceps swept medially

- protect musculocutaneous nerve between the two

- will emerge as lateral cutaneous nerve of the forearm distally

- identify and split brachialis in midline

- can reflect brachialis medially, but will potentially damage radial innervation of medial brachialis


Distal extension

- between brachialis and brachioradialis in distal 1/4

- find and protect radial nerve as it emerges anteriorly through lateral intermuscular septum

- may be easiest to find radial nerve most distally between brachialis and bradioradialis

- avoid lateral hohman retractors in this area


Internervous plane

- radial nerve lateral brachialis

- musculocutaneous nerve medial brachialis



- narrow large fragment 4.5 mm DCP / long Philos proximal humeral plate

- minimum 6 cortices above and below


B.  Posterior Approach and triceps split for Distal 1/3 fractures


Humerus ORIF Posterior Approach


AO foundation surgical approach


Vumedi video



- distal 1/3 fractures

- holstein-lewis fractures



- lateral approach with arm over bolster


Midline incision

- split deep fascia



- develop interval between long and lateral heads of triceps (easiest in muscle bellies proximally)

- identify radial nerve and profunda brachii artery proximally in spiral groove

- release lateral head of triceps from humerus

- limited by axillary nerve / posterior circumflex humeral artery proximally



- split triceps tendon

- reflect medial head of triceps from bone medially

- care of ulna nerve which emerges posteriorly through medial intermuscular septum


C. Posterior approach with triceps sparing for Holstein Lewis


AO foundation radial window distal humerus




Holstein Lewis / distal humerus fracture




Patient lateral with arm over bolster


A. Mobilise the lateral triceps from lateral intermuscular septum

- identify the radial nerve lateral to triceps 

- follow as it passes through the lateral intermuscular septum

- identify as passes across the humerus in the groove

- may have to elevate the radial nerve and pass the plate under


Triceps flip Triceps flip 2




Precontoured long posterolateral distal humerus plates


Triceps flip plate 1Triceps flip 2


Humerus distal posterolateral plate 1Distal posterolateral plate 2

Posterolateral plate


B.  Proximal window between long and lateral heads

- slide plate under radial nerve

- fix with screws proximal and distal


Humerus # 1Distal humerus approachDistal humerus 2


Humerus # 2Humerus # 3


C. Can also mobilise medial triceps

- identify and release the ulna nerve medially

- additional medial plate if needed


Dis HumerusLateral humerusMedial humerus

Distal humerus fracture                 Lateral plate                                        Medial plate with ulna nerve tagged


2. Minimally Invasive Plate Osteosynthesis (MIPO)




Bridge plating

Indirect fracture reduction




Surgical neck of humerus to 10 cm of elbow joint




Anterior plating with narrow 4.5 mm LCP

Lateral plating with long proximal humerus plate


Jeong et al. BMC Musculoskeletal Disorders

- 18 patients treated with narrow LCP (anterior)

- 17 patients treated with long Philos plate (lateral)

- 2 metal failures in the Philos plate group requiring revision to LCP


Technique anterior MIPO plating


Tetsworth JAAOS 2018



- patient supine

- arm on arm table

- ensure can image proximal humerus

- keep elbow flexed to aid reduction and reduce biceps tension


Narrow LCP plate

- place on arm to select appropriate size


MIPO humerus 1MIPO humerus 3MIPO humerus 2




Proximal 4 - 5 cm

- deltopectoral approach


Distal 4 - 5 cm

- anterior approach to distal humerus

- mobilise biceps laterally

- identify and protect lateral cutaneous nerve of the forearm

- split bracialis

- keep arm supinated to protect radial nerve

- avoid deep retractors laterally to protect radial nerve


Create submuscular plane

- periosteal elevator along bone


Precontour narrow LCP plate

- subtle convex curve proximally

- subtle concave curve distally

- 10 - 15 degrees internally rotated


Pass plate

- indirect fracture reduction

- secure plate proximally to bone

- reduce fracture

- distal fixation


MIPO incisions 1MIPO incisions 2MIPO incisions 3MIPO plate insertion


3.  Antegrade Humeral Nail


Humeral Nail APHumeral Nail Lateral


Relative indications


Segmental fracture - need very long plate

Impending pathological fracture


Skin compromise




Vumedi video


Set up

- lazy beach chair

- can do flat on bed, with bump under shoulder

- need to get fluoroscopy of shoulder and distal forearm

- have fluroscopy come from opposite side

- patient relatively supine to ensure ease of AP distal locking


Anterolateral approach shoulder

- longitudinal split supraspinatus

- can split at the anterior edge of supraspinatus, and retract posteriorly

- protect rotator cuff throughout


Entry with K wire or awl

- entry point at medial aspect greater tuberosity

- theorectically protects the cuff tendon

- check centred in humerus canal using fluoroscopy on AP and lateral

- increase diameter proximally with hand reamers


Pass guide wire

- can do closed

- can perform mini open incision over fracture site

- use finger to blunt dissect and protect radial nerve


Minimal reaming


Pass nail

- typically 7 mm

- ensure that nail is buried enough to protect cuff

- need to consider hardware removal


Proximal locking screws

- ensure not in joint

- lateral and anterolateral

- protect biceps tendon


Distal AP locking screw/s


Careful repair of rotator cuff




Rotator cuff pain

- must not leave nail prominent

- must carefully repair cuff


Humerus Prominent IM Nail


Non Union






Mean time to union is 13 weeks

No evidence of callous on xrays taken 6 - 8 weeks apart


Fracture patterns

- highest risk is transverse fractures

- proximal humerus shaft fractures also at risk due to displacing force of pectoralis and deltoid, and LHB may interpose




Peters et al. Injury 2015

- systematic review of union rate after operative intervention of humeral shaft non union

- plate only 95%

- plate and bone graft 98%

- IMN 66%

- IMN + bone graft 88%

- external fixation 98%




Vumedi video


Humerus nonunion plateHumerus nonunionHumerus nonuion plate 1Humerus nonunion plate 2



- fracture site dependant

- 4.5 mm plate with 6 cortices above and below

- if use 3.5 mm long proximal humeral plate, suggest 8 cortices below

- use iliac crest bone graft

- consider dual plating in proximal fractures with insufficient fixation, or in poor bone quality




Humerus infection 1Humerus infected 2