Makindo Medical Notes

Humerus Fractures 💪🦴 are common injuries, particularly in older adults with osteoporosis. Key priorities: neurovascular assessment (radial & axillary nerves, brachial artery) and appropriate referral. If there are neurological/vascular deficits or joint involvement → urgent orthopaedic input.

📖 About

• Neck of Humerus Fractures: common in elderly, usually after a fall on an outstretched hand (FOOSH); associated with degenerative bone disease.
• Shaft of Humerus Fractures: often rotational injuries (e.g. arm wrestling); also seen in metastatic disease. ⚠️ Assess and document radial nerve function (wrist extension + sensation in 1st web space).

⚙️ Aetiology

• Trauma (falls, direct blow, arm-wrestling)
• Osteoporosis
• Paget’s disease
• Pathological fractures (e.g. metastases)
• May involve: greater tuberosity, lesser tuberosity, anatomical neck, surgical neck

🩺 Clinical Features

• Localised pain, swelling, tenderness; arm may hang limply with bruising.
• ⚡ Neurovascular exam:
  • Radial nerve: wrist extension + sensation in 1st dorsal web space.
  • Axillary nerve: sensation over regimental badge area + deltoid power.
  • Brachial plexus screen + distal neuro exam.
  • Check radial pulse & perfusion.

🔎 Types

• Proximal humerus: FOOSH, seizures, direct trauma; older patients; axillary nerve vulnerable.
• Midshaft: commonly affects radial nerve (spiral groove injury).

🧪 Investigations

• Bloods: FBC, ESR, U&E, Ca (esp. if pathological fracture suspected).
• Imaging:
  • X-ray: humerus AP, scapular Y, axillary views.
  • CT if complex or intra-articular involvement.

⚠️ Complications

• Nerve injuries:
  • Axillary nerve → proximal fractures.
  • Radial nerve → midshaft fractures.
  • Suprascapular & musculocutaneous less common.
• Vascular injury: axillary or brachial artery (expanding mass, absent pulses).
• Avascular necrosis: humeral head after complex or anatomical neck fractures.
• Malunion, stiffness, rotator cuff injury.
• Fracture dislocations.

💊 Management

• General: Analgesia, sling/immobilisation, neurovascular monitoring, fracture clinic referral.
• Proximal (neck of humerus):
  • Most are undisplaced → conservative (collar & cuff or sling; allow gravity traction).
  • Physiotherapy + analgesia.
• Shaft of humerus:
  • 2-part fracture: humeral brace, post-reduction X-ray, fracture clinic.
  • 3+ part fracture / unstable: brace + urgent orthopaedic referral (possible fixation).
  • Always re-document radial nerve status.

🚨 Surgical Emergencies

• Open fractures.
• Associated with shoulder dislocation.
• Combined injuries (e.g. ipsilateral forearm fracture → “floating elbow”).
• Anatomical neck fractures (high AVN risk).
• Neurovascular compromise not resolving with reduction.

📌 OSCE / Exam Pearls

• Always document radial & axillary nerve function before and after any intervention.
• Look for expanding swelling = axillary artery injury.
• Most proximal humeral fractures in elderly = sling + analgesia; surgical if displaced/complex.
• Radial nerve palsy in closed shaft fractures often recovers spontaneously → observe unless open fracture.

📚 References

• Rockwood & Green’s Fractures in Adults, 9th ed.
• NICE: Non-complex fractures (NG38). 2016.
• British Orthopaedic Association: BOAST guidelines on humeral fractures.