Humeral shaft fractures account for 1–3% of all fractures in adults, with an incidence of approximately 12–14.5 per 100,000 per year. [1-2] They result in approximately 60,000 ED visits annually in the United States. [3] The age distribution is bimodal: low-energy falls in older adults (especially women) and high-energy trauma in younger patients (especially men). [1][4-5]
1. History
- Mechanism of injury: Simple fall (most common, ~60–70%), motor vehicle crash, sports injury, direct blow, or twisting injury [2-3][5]
- Symptom characterization: Acute upper arm pain, inability to use the arm, swelling, deformity, crepitus
- Timing: Acute onset with trauma; ask about preceding arm weakness or pain (pathological fracture concern)
- Associated symptoms: Numbness/tingling in the hand (radial nerve distribution — dorsal first web space), wrist/finger drop, elbow or shoulder pain
- Important negatives: Ability to extend wrist and fingers (rules out radial nerve palsy), intact sensation, no open wound, no history of cancer or metabolic bone disease
2. Alarm Features
- Radial nerve palsy (wrist drop, finger drop, dorsal hand numbness) — present in ~10% of closed fractures, up to 25% in high-energy injuries [1][6-7]
- Open fracture — occurs in ~2–3% of cases [4-5]
- Vascular injury (absent/diminished distal pulses, expanding hematoma) — rare but associated with 52× increased odds of nerve palsy [6]
- Compartment syndrome — tense swelling, pain with passive stretch
- Polytrauma — humeral shaft fractures in trauma patients carry a 21% mortality rate and are associated with head injuries and other fractures in 74% [8]
- Pathological fracture — ~4–8% of humeral shaft fractures; suspect with minimal trauma, history of cancer, or lytic lesion on radiograph [2][4]
- Floating elbow — ipsilateral forearm fracture requiring urgent surgical evaluation [2]
3. Medications
- Acute pain management: NSAIDs (ibuprofen 400–600 mg q6h, ketorolac 15–30 mg IV), acetaminophen, opioids for severe pain (oxycodone 5–10 mg q4–6h PRN)
- Avoid: Excessive opioid prescribing; consider multimodal analgesia
- Anticoagulants: Note if patient is on anticoagulation (increases hematoma risk, complicates surgical planning)
- Bone health: In elderly patients with fragility fractures, consider initiating calcium/vitamin D and referral for osteoporosis workup [5]
- Tetanus prophylaxis: If open fracture
- Antibiotics: Required for open fractures per Gustilo classification
4. Diet
- Adequate calcium and vitamin D intake for fracture healing
- Protein-rich diet to support bone repair
- Hydration: Standard recommendations; no specific dietary triggers
- Long-term: Osteoporosis screening and dietary counseling in elderly patients with fragility fractures
5. Review of Systems
- Neurologic: Wrist/finger extension, grip strength, sensation in radial nerve distribution (dorsal first web space), ulnar and median nerve function
- Vascular: Distal pulses, capillary refill, hand color/temperature
- Musculoskeletal: Shoulder and elbow pain/ROM, ipsilateral forearm injury (floating elbow), cervical spine symptoms
- Constitutional: Weight loss, night pain, fatigue (pathological fracture red flags)
- Skin: Open wounds, skin tenting, ecchymosis
6. Collateral History and Family History
- Mechanism details from witnesses (especially in elderly falls, MVCs, or altered patients)
- Functional baseline: Dominant hand, occupation, activity level — critical for treatment decision-making [1]
- History of cancer: Breast, lung, prostate, renal, thyroid (common sources of humeral metastases)
- Osteoporosis/fragility fracture history in family
- Child abuse: In children <3 years, humeral shaft fractures are a sentinel injury for non-accidental trauma [9]
- Social context: Ability to comply with brace management, living situation, substance use
7. Risk Factors
- Elderly women (fragility/low-energy falls) [4-5]
- Young men (high-energy trauma, sports, MVCs) [4]
- Osteoporosis/osteopenia — proximal and middle-third fractures should be considered fragility fractures [5]
- Alcohol excess — associated with proximal-third fractures [5]
- Metastatic bone disease (4–8% are pathological) [2][4]
- Periprosthetic fractures (~2.5%) in patients with shoulder arthroplasty [2][4]
8. Differential Diagnosis
- Proximal humerus fracture — pain/deformity more at shoulder; different management
- Pathological fracture — minimal trauma, lytic lesion on X-ray; suspect malignancy or metabolic bone disease
- Periprosthetic fracture — fracture around existing shoulder prosthesis [4]
- Humeral stress fracture — overuse in athletes (throwers); no acute trauma
- Soft tissue injury (biceps/triceps rupture, contusion) — no bony abnormality on imaging
- Brachial plexus injury — neurologic deficits without fracture
- Shoulder dislocation — deformity at shoulder, not mid-arm
9. Past Medical History
- Prior upper extremity fractures or surgeries
- Known osteoporosis or metabolic bone disease
- History of malignancy (especially breast, lung, prostate, renal, thyroid)
- Parkinson's disease or neurologic conditions affecting arm use (relative indication for surgery) [2]
- Bilateral arm injuries or only one functional arm
- Obesity (complicates brace management) [2]
- Chronic conditions affecting healing: diabetes, smoking, immunosuppression
10. Physical Exam
- Inspection: Swelling, deformity, shortening, ecchymosis ("gravity sign" tracking to elbow/forearm), skin integrity (open fracture)
- Palpation: Point tenderness over humeral shaft, crepitus, abnormal mobility
- Neurovascular exam (critical):
- Radial nerve: Wrist extension, finger MCP extension, sensation over dorsal first web space — most commonly injured nerve [6-7]
- Ulnar nerve: Finger abduction/adduction, sensation of small finger
- Median nerve: Thumb opposition, index finger flexion, sensation of palmar index finger
- Vascular: Radial and ulnar pulses, capillary refill
- Shoulder and elbow ROM: Assess for associated injuries
- Skin: Check for open wounds, skin tenting, impending open fracture
11. Lab Studies
- Routine labs are generally not needed for isolated, closed fractures in healthy patients
- Trauma workup (polytrauma): CBC, BMP, type and screen, coagulation studies, lactate
- Pathological fracture suspected: CBC, CMP (calcium, alkaline phosphatase), ESR/CRP, serum protein electrophoresis (SPEP), PSA (males), TSH
- Preoperative labs if surgery planned: CBC, BMP, coagulation studies, type and screen
12. Imaging
- First-line: AP and lateral radiographs of the entire humerus including shoulder and elbow joints — sufficient for diagnosis in the vast majority of cases [1-2]
- CT scan: Reserved for complex fracture patterns, intra-articular extension, or preoperative planning [1]
- MRI: For suspected pathological fractures or occult fractures not seen on X-ray [1]
- Key radiographic findings: Fracture location (proximal, middle, distal third), pattern (transverse, oblique, spiral, comminuted), displacement, angulation
- Acceptable alignment for nonoperative management: <30° varus/valgus and <20° anterior/posterior angulation [10-11]
- Imaging is unnecessary for follow-up if clinically healing well and no change in symptoms (though serial radiographs are standard practice)
13. Special Tests
- AO/OTA Classification (12A, B, C): Simple, wedge, and complex fracture types [2]
- Gustilo-Anderson Classification: For open fractures (guides antibiotic and surgical management)
- Electrodiagnostic studies (EMG/NCS): Recommended if no sign of radial nerve recovery by 9 weeks; useful for distinguishing neuropraxia from axonotmesis/neurotmesis [6]
- Point-of-care ultrasound: Can identify fracture and hematoma at bedside but not standard
- DEXA scan: Consider in elderly patients with fragility fractures (outpatient)
14. ECG
- Not routinely indicated for isolated humeral shaft fractures
- Obtain if:
- Polytrauma or significant mechanism
- Elderly patient with syncope-related fall (rule out arrhythmia as cause of fall)
- Preoperative evaluation if surgery planned and patient has cardiac risk factors
15. Assessment
Humeral shaft fractures are classified by location (proximal, middle, or distal third — middle third is most common at ~48%) and morphology (simple, wedge, complex). [5] The majority result from low-energy falls in older adults. Key clinical considerations:
- Severity stratification: Isolated closed fracture with intact neurovascular exam = lower acuity; open fracture, vascular injury, polytrauma, or radial nerve palsy = higher acuity
- Typical presentation: Pain, swelling, deformity of the upper arm with inability to use the extremity
- Atypical presentations: Pathological fracture with minimal trauma; stress fracture in athletes; child abuse in young children
- Complications: Nonunion (up to 25% with bracing), radial nerve palsy (~10%), malunion, infection (surgical), shoulder/elbow stiffness [1][12]
16. Treatment Plan
Initial stabilization (ED)
- Immobilization with coaptation (sugar-tong) splint, posterior long-arm splint, or sling — all are acceptable; choice can be guided by patient comfort and resource availability, as no significant difference in alignment outcomes has been demonstrated [11]
- Adequate analgesia (multimodal: acetaminophen + NSAID ± opioid)
- Neurovascular exam documentation before and after splinting
Nonoperative management (majority of isolated, closed fractures):
- Transition to functional (Sarmiento) brace at 7–10 days once swelling subsides [1][3][13]
- Immediate pendulum exercises of shoulder, active elbow/hand ROM
- Gradual weight-bearing at 6 weeks [3]
- Union achieved in ~10 weeks in >89% of cases [10][12]
- Acceptable angulation: <30° coronal, <20° sagittal [10]
Operative management — indications include: [2][14]
- Open fractures (Gustilo II/III)
- Polytrauma / high-energy injuries
- Vascular injury requiring repair
- Floating elbow (ipsilateral forearm fracture)
- Bilateral humeral fractures
- Pathological fractures
- Failure of nonoperative management (nonunion)
- Patient preference after shared decision-making (especially working-age patients) [1]
Surgical options: ORIF with plate and screws (gold standard), minimally invasive plate osteosynthesis (MIPO — lowest complication and nonunion rates), intramedullary nailing. [12][15] Surgery provides faster early recovery and lower nonunion rates (0.7–6% vs. 15–25%), but long-term outcomes at 12 months are similar to successful bracing. [3][16-17]
Radial nerve palsy management
- Primary RNP: >90% recover spontaneously — observation is standard [1][6-7]
- EMG/NCS if no recovery by 9 weeks [6]
- Late exploration recommended if no recovery by 6 months [18]
- If nerve recovery has not occurred by 7 months, probability of recovery by 18 months is still ~56%; by 12 months without recovery, probability drops to ~17% [19]
17. Disposition
Discharge criteria (most isolated, closed fractures)
- Adequate pain control with oral medications
- Intact neurovascular exam
- Appropriate immobilization in place
- Orthopedic follow-up arranged within 7–10 days
- Patient understands brace care and activity restrictions
Admission criteria
- Open fracture requiring operative debridement
- Vascular injury
- Polytrauma / associated injuries requiring inpatient management
- Inability to manage pain as outpatient
- Compartment syndrome (emergent fasciotomy)
Observation indications
- Elderly patients with fall-related injuries needing social/safety evaluation
- Patients on anticoagulation with large hematoma
Specialist consultation triggers
- Orthopedic surgery: All humeral shaft fractures should have orthopedic follow-up; emergent consult for open fractures, vascular injury, floating elbow, compartment syndrome
- Vascular surgery: If diminished/absent pulses or expanding hematoma
- Hand surgery/neurology: If radial nerve palsy does not recover by 9 weeks [6]
18. Follow Up / Return Precautions
Follow-up timing
- 7–10 days: Orthopedic clinic for repeat radiographs, conversion to functional brace, reassessment of alignment and neurovascular status [13]
- 3 and 9 weeks: Physical therapy appointments for guided rehabilitation [3]
- 6 weeks, 3 months, 6 months, 12 months: Serial clinical and radiographic assessment [16]
- Fractures not showing union by 6–10 weeks are at risk for nonunion and may need a change in management [20]
Return precautions — instruct patients to return immediately for:
- New or worsening numbness/tingling in the hand
- Inability to extend wrist or fingers (new wrist drop)
- Increasing pain despite medications
- Skin breakdown, wound drainage, or signs of infection
- Fever
- Loss of pulse or color change in the hand
- Brace loosening with increased deformity
Patient counseling
- ~70% of patients treated with bracing heal uneventfully [3]
- Nonunion risk with bracing is 15–25%; if nonunion occurs, surgery is effective [1][3]
- Expect functional recovery over 3–6 months; long-term outcomes are generally good regardless of treatment modality [16-17]
- Avoid lifting, pushing, or weight-bearing with the affected arm for at least 6 weeks [3]
Images
References
1. An Acta Orthopaedica Educational Article: Treatment of Adult Patients With a Humeral Shaft Fracture. — Ibounig T, Wolf O, Oliver WM, et al. Acta Orthopaedica. 2026.
2. Surgical Versus Non-Surgical Interventions for Treating Humeral Shaft Fractures in Adults. — Gosler MW, Testroote M, Morrenhof JW, Janzing HM. The Cochrane Database of Systematic Reviews. 2012.
3. Effect of Surgery vs Functional Bracing on Functional Outcome Among Patients With Closed Displaced Humeral Shaft Fractures: The FISH Randomized Clinical Trial. — Rämö L, Sumrein BO, Lepola V, et al. The Journal of the American Medical Association. 2020.
4. Epidemiology of 936 Humeral Shaft Fractures in a Large Finnish Trauma Center. — Mattila H, Keskitalo T, Simons T, Ibounig T, Rämö L. Journal of Shoulder and Elbow Surgery. 2023.
5. Fractures of the Proximal- And Middle-Thirds of the Humeral Shaft Should Be Considered as Fragility Fractures. — Oliver WM, Searle HKC, Ng ZH, et al. The Bone & Joint Journal. 2020.
6. Predictors of Traumatic Nerve Injury and Nerve Recovery Following Humeral Shaft Fracture. — Entezari V, Olson JJ, Vallier HA. Journal of Shoulder and Elbow Surgery. 2021.
7. Radial Nerve Palsy Associated With Closed Humeral Shaft Fractures: A Systematic Review of 1758 Patients. — Hendrickx LAM, Hilgersom NFJ, Alkaduhimi H, Doornberg JN, van den Bekerom MPJ. Archives of Orthopaedic and Trauma Surgery. 2021.
8. Humerus Fractures at a Regional Trauma Center: An Epidemiologic Study. — Bercik MJ, Tjoumakaris FP, Pepe M, et al. Orthopedics. 2013.
9. Pediatric Fractures of the Humerus. — Caviglia H, Garrido CP, Palazzi FF, Meana NV. Clinical Orthopaedics and Related Research. 2005.
10. Acute and Chronic Humeral Shaft Fractures in Adults. — Pidhorz L. Orthopaedics & Traumatology, Surgery & Research : OTSR. 2015.
11. Effect of Initial Immobilization Type on the Management of Humeral Shaft Fractures. — Sethi S, Zhang D, Kumar M, Strelzow JA, Christiano AV. Injury. 2025.
12. Humeral Shaft Fracture: Systematic Review of Non-Operative and Operative Treatment. — Van Bergen SH, Mahabier KC, Van Lieshout EMM, et al. Archives of Orthopaedic and Trauma Surgery. 2023.
13. Nonoperative Treatment of Humeral Shaft Fractures Revisited. — Ali E, Griffiths D, Obi N, Tytherleigh-Strong G, Van Rensburg L. Journal of Shoulder and Elbow Surgery. 2015.
14. Management of Humeral Shaft Fractures. — Carroll EA, Schweppe M, Langfitt M, Miller AN, Halvorson JJ. The Journal of the American Academy of Orthopaedic Surgeons. 2012.
15. Management of Humeral Shaft Fracture: A Network Meta-Analysis of Individual Treatment Modalities. — Colasanti CA, Anil U, Cerasani MN, et al. Journal of Orthopaedic Trauma. 2024.
16. Operative vs Nonoperative Management of Fractures of the Humeral Diaphysis: The Humeral Shaft Fracture Fixation Randomized Clinical Trial. — Oliver WM, Bell KR, Carter TH, et al. JAMA Surgery. 2025.
17. Surgical Versus Nonsurgical Management of Humeral Shaft Fractures: A Systematic Review and Meta-Analysis of Randomized Trials. — Oliver WM, Bell KR, Molyneux SG, et al. The Journal of the American Academy of Orthopaedic Surgeons. 2023.
18. Primary Radial Nerve Lesions in Humerus Shaft Fractures-Revision or Wait and See. — Böhringer A, Cintean R, Schütze K, Gebhard F. Journal of Clinical Medicine. 2024.
19. What Is the Probability of Radial Nerve Recovery After Surgical Repair of Humerus Fractures Accounting for Time Since Injury?. — Krijnen NA, Comerci AJ, Head LK, et al. Clinical Orthopaedics and Related Research. 2026.
20. Fractures of the Humeral Shaft: A Retrospective Study of 240 Adult Fractures. — Mast JW, Spiegel PG, Harvey JP, Harrison C. Clinical Orthopaedics and Related Research. 1975.