Humeral shaft fractureMANAGEMENT

ARM & ELBOW · 12 SECTIONS

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465 items

☷ Legend

01Approach to the Critical Patient/attcp53

Immediate priorities

›Initial stabilization

›Airway compromise triggers

›Altered mental status with trauma

›Facial trauma with airway risk

›Breathing compromise triggers

›Hypoxia

›Respiratory distress

›Circulation compromise triggers

›Hypotension with long bone trauma

›Ongoing external bleeding

›Disability and exposure priorities

›GCS trend

›Full limb exposure for open injury and skin threat

Limb threat screen

›Neurovascular threat

›Radial pulse and Doppler if equivocal

›Absent pulse triggers immediate escalation

›New pulse change after splinting triggers immediate loosening and recheck

›Capillary refill and skin temperature

›Cool pale hand triggers vascular injury concern

›Mottling triggers shock or arterial injury concern

›Motor function

›Wrist extension and finger MCP extension for radial nerve

›Thumb IP extension for posterior interosseous nerve

›Sensory function

›Dorsal first web space sensation for radial nerve

›Median and ulnar distribution comparison

›Documentation checkpoints

›Before immobilization

›After immobilization

›After any manipulation

Open fracture pathway

›Open injury risk

›Wound near fracture site

›Any puncture treated as open until proven otherwise

›Bleeding through dressings

›Contamination risk

›Farm or soil exposure

›Water exposure

›Time sensitive actions

›Antibiotics within 60 minutes when feasible

›Tetanus prophylaxis based on status

Consultation and transfer triggers

›Escalation triggers

›Open fracture

›Immediate orthopedics notification

›Transfer if no operative capability

›Vascular injury concern

›Immediate orthopedics and vascular surgery pathway

›Transfer if no vascular capability

›Compartment syndrome concern

›Immediate orthopedics

›Avoid regional block masking progression

›Polytrauma context

›Trauma team activation per local protocol

›CT trauma series as indicated

02History/hx43

Injury context

›Mechanism and timing

›High energy mechanism

›MVC

›Fall from height

›Low energy mechanism

›Ground level fall in older adult

›Torsional injury during sports

›Time since injury

›Swelling progression

›Prior manipulation attempts

Functional baseline and risks

›Patient factors

›Hand dominance

›Dominant arm injury functional impact

›Occupational demands

›Baseline function

›Prior shoulder or elbow limitation

›Prior neurologic deficit

›Bone health

›Osteoporosis history

›Chronic glucocorticoid use

›Bleeding risk

›Anticoagulants and antiplatelets

›Bleeding disorder

Red flags and associated injury mapping

›Limb threat symptoms

›Numbness or tingling in hand

›Dorsal first web space involvement

›Progressive sensory change

›Weakness

›Wrist drop

›Finger extension weakness

›Severe escalating pain

›Pain out of proportion

›Pain with passive finger stretch

›Skin threat

›Tenting

›Blanching

›Associated injuries

›Shoulder pain suggesting proximal extension

›Glenohumeral dislocation concern

›Proximal humerus fracture concern

›Elbow pain suggesting distal extension

›Elbow dislocation concern

›Distal humerus fracture concern

03Physical Exam/exam54

General and local exam

›Global assessment

›Hemodynamic status

›Shock physiology

›Need for analgesia before full exam

›Secondary survey completeness

›Chest wall and clavicle tenderness

›Cervical spine considerations when mechanism supports

›Arm inspection and palpation

›Deformity and swelling

›Varus or valgus angulation

›Shortening

›Skin integrity

›Open wound

›Fracture blisters

›Threatened skin

›Tenting

›Blanching

›Tenderness mapping

›Fracture site localization

›Pain at shoulder or elbow suggesting extension

Neurovascular exam

›Distal perfusion

›Radial pulse quality

›Symmetry with contralateral side

›Doppler augmentation if needed

›Capillary refill

›Delayed refill

›Pallor

›Nerve exam focus

›Radial nerve motor

›Wrist extension

›Finger MCP extension

›Radial nerve sensory

›Dorsal first web space

›Dorsolateral hand

›Median nerve screen

›Thumb opposition

›Palmar index sensation

›Ulnar nerve screen

›Finger abduction

›Palmar little finger sensation

Joint above and below

›Shoulder and elbow evaluation

›Shoulder

›Passive ROM limited by pain

›Dislocation signs

›Elbow

›ROM limitation

›Olecranon and radial head tenderness

PITFALLS

›Common misses

›Radial nerve palsy documentation absent before splinting

›Pre splint neurovascular status required for attribution

›Post splint change triggers immediate reassessment

›Inadequate imaging excluding joints

›Shoulder and elbow inclusion for long bone trauma

›Missed associated fracture or dislocation

04Differential Diagnosis/ddx26

Traumatic mimics and co-injuries

›Upper arm pain and deformity causes

›Humeral shaft fracture

›ICD-10 S42.3

›SNOMED CT humeral shaft fracture concept

›Proximal humerus fracture

›Greater tuberosity fracture

›Surgical neck fracture

›Distal humerus fracture

›Supracondylar extension pattern in adults

›Intercondylar extension

›Shoulder dislocation

›Anterior dislocation

›Posterior dislocation after seizure or electrocution

›Elbow dislocation

›Posterior dislocation

›Fracture dislocation patterns

Limb threatening diagnoses

›Time critical complications

›Vascular injury

›Brachial artery injury concern with absent distal pulse

›Expanding hematoma

›Compartment syndrome of arm

›Disproportionate pain

›Pain with passive finger stretch

›Open fracture and deep infection risk

›Wound communication

›Contamination exposure

05Laboratory Tests/lt27

Minimal labs for isolated closed fracture

›Selective testing

›No routine labs for uncomplicated isolated closed injury

›Imaging driven management

›Clinical stability driven disposition

›Pregnancy testing when indicated

›Reproductive age with imaging planned

›Medication selection implications

Labs for operative pathway or complications

›Pre procedural or operative considerations

›CBC for bleeding concern

›Significant ecchymosis or swelling

›Anticoagulant use

›Electrolytes and creatinine for sedation pathway

›Significant comorbidity

›Anticipated contrast imaging

›Coagulation studies when anticoagulated

›Warfarin or DOAC history

›Planned procedure or surgery

›Type and screen for major trauma

›Hypotension

›Polytrauma

Infection and open fracture context

›Open injury labs

›CBC for systemic illness concern

›Fever

›Delayed presentation with wound

›Lactate for shock concern

›Hypotension

›Poor perfusion signs

06Diagnostic Tests/dt42

Scoring Systems

›Classification frameworks

›AO OTA humerus diaphysis

›12 A simple

›12 B wedge

›12 C complex

›Pattern specific labels

›Spiral distal third with radial nerve risk

›Holstein Lewis pattern concept

›Open fracture grading when applicable

›Gustilo Anderson type I

›Gustilo Anderson type II

›Gustilo Anderson type III

Radiographs

›Plain film evaluation

›Views

›Humerus AP

›Humerus lateral

›Joint inclusion

›Shoulder included

›Elbow included

›Alignment description elements

›Location proximal middle distal third

›Angulation direction and magnitude

›Post immobilization imaging

›After coaptation splint

›After any manipulation

MRI

›Soft tissue and occult pathways

›Suspected pathologic fracture

›Malignancy concern

›Atypical fracture pattern

›Persistent pain with negative radiographs

›Occult fracture consideration

›Bone marrow edema detection

›Advanced imaging indications

›Intra articular extension concern

›Distal extension toward elbow joint

›Proximal extension toward shoulder region

›Preoperative planning

›Complex comminution

›Segmental fracture

›Vascular injury evaluation adjunct

›CT angiography when pulse deficit or hard signs

›ACEP Level C for imaging choice by local trauma protocol

07Disposition/dispo30

ED disposition criteria

›Discharge pathway

›Closed fracture

›Pain controlled on oral regimen

›Stable neurovascular exam

›Reliable follow up

›Orthopedics arranged

›Return precautions understood

›Safe home function

›Sling tolerance

›Support available if needed

›Admission or transfer pathway

›Open fracture

›IV antibiotics started

›Operative capability required

›Neurovascular compromise

›Persistent radial pulse abnormality

›New or worsening neurologic deficit after reduction or splinting

›Compartment syndrome concern

›Escalating pain despite analgesia

›Tense compartments

›Polytrauma or unstable vitals

›Trauma service admission

›Ongoing resuscitation needs

Follow up timing

›Orthopedics follow up expectations

›Closed uncomplicated fracture

›Follow up within 7 days

›Earlier if increasing deformity or pain

›Radial nerve palsy present

›Close follow up within 72 hours to 7 days

›Document baseline deficit clearly

08Treatment/t94

Immediate life-saving interventions

›Time critical actions

›Hemorrhage and shock management when present

›IV access and resuscitation per trauma protocol

›Blood products for hemorrhagic shock

›Limb ischemia actions when present

›Immediate orthopedics and vascular escalation

›Avoid delays for imaging when hard signs

›Constriction relief

›Ring removal early

›Tight bandage loosening

Immobilization and Splinting

›Immobilization strategy

›Splint selection

›Coaptation splint

›Sling and swathe

›Principles

›Joint above and below support

›Avoid circumferential cast in swelling phase

›Technique elements

›Padding over bony prominences

›Three point molding for alignment support

›Post application checks

›Radial pulse and cap refill

›Radial nerve motor and sensory reassessment

Reduction

›Alignment and skin threat management

›Indications for manipulation

›Threatened skin tenting

›Marked angulation with functional compromise

›Caution triggers

›Suspected vascular injury

›Open fracture requiring antibiotics and tetanus first when feasible

›Analgesia and anesthesia options

›Non opioid baseline

›Acetaminophen PO 1000 mg

›Ibuprofen PO 400 mg to 600 mg

›Opioid titration for severe pain

›Morphine IV 2 mg

›Repeat every 5 to 10 minutes to effect

›Typical total 0.05 mg per kg to 0.1 mg per kg

›Fentanyl IV 25 micrograms

›Repeat every 5 minutes to effect

›Typical total 1 microgram per kg to 2 micrograms per kg

›Procedural sedation when required

›Monitoring and readiness

›Continuous pulse oximetry

›Capnography when available

›Ketamine IV 1 mg per kg

›Additional 0.25 mg per kg to 0.5 mg per kg as needed

›ACEP Level B for ketamine safety in ED procedural sedation

›Propofol IV 0.5 mg per kg

›Additional 0.25 mg per kg to 0.5 mg per kg titration

›ACEP Level B for propofol procedural sedation with appropriate monitoring

›Technique principles

›Gentle longitudinal traction

›Countertraction at proximal arm

›Avoid repeated forceful attempts

›Post manipulation requirements

›Immediate neurovascular recheck

›Post manipulation radiographs

›Failed manipulation pathway

›Persistent deformity with threatened skin triggers urgent orthopedics

›Any worsening neurovascular findings triggers immediate escalation

Open fracture medications and timing

›Infection prevention bundle

›Antibiotics timing

›First dose as early as feasible

›Goal within 60 minutes when feasible

›Antibiotic selection

›Cefazolin IV 2 g

›Repeat every 8 hours while awaiting operative care

›Class I recommendation by orthopedic trauma consensus for early prophylaxis

›Severe beta lactam allergy option

›Clindamycin IV 900 mg

›Repeat every 8 hours while awaiting operative care

›Gross contamination or farm exposure option

›Add gentamicin IV 5 mg per kg

›Single daily dosing per local protocol

›Tetanus prophylaxis

›Unknown or incomplete immunization

›Tdap

›Tetanus immune globulin for dirty wounds per immunization status

›Up to date immunization

›Tdap booster per timing and wound category

›Wound care

›Sterile saline moistened dressing

›Avoid probing in ED

DVT prophylaxis when relevant

›Thrombosis prevention considerations

›Routine pharmacologic prophylaxis not typical for isolated upper extremity immobilization

›Individual risk assessment

›Align with local protocol

›Elevated risk features

›Prior VTE

›Active malignancy

›Documentation elements

›Rationale for prophylaxis or no prophylaxis

›Follow up plan for reassessment

09Special Populations/sp30

Pregnancy

›Pregnancy considerations

›Imaging principles

›Extremity radiographs generally low fetal dose

›Shielding based on local policy

›Analgesia considerations

›Acetaminophen preferred

›NSAID avoidance in later pregnancy based on gestational age guidance

›Trauma considerations

›Maternal stabilization priority

›Rh status and fetomaternal hemorrhage evaluation per trauma protocol

Geriatric

›Older adult considerations

›Fragility fracture context

›Osteoporosis risk assessment

›Fall risk evaluation

›Medication sensitivity

›Opioid delirium risk

›Dose reduction and slower titration

›Disposition threshold

›Higher admission threshold for unsafe home supports

›Early PT and OT involvement when admitted

Pediatrics

›Pediatric considerations

›Growth plate and remodeling

›Proximal humerus remodeling differs from diaphysis

›Angulation tolerance varies with age and location

›Non accidental trauma screen when indicated

›Inconsistent history

›Additional injuries

›Weight based analgesia

›Acetaminophen PO 15 mg per kg

›Ibuprofen PO 10 mg per kg

10Background/b30

Epidemiology

›Population patterns

›Injury mechanisms

›Falls and sports in younger patients

›Falls in older adults

›Common complication frequency context

›Radial nerve palsy is a recognized association

›Open fracture less common than tibia but clinically significant when present

Pathophysiology

›Biomechanics and anatomy

›Force vectors

›Torsion associated with spiral patterns

›Bending associated with transverse patterns

›Radial nerve proximity

›Spiral groove course increases vulnerability

›Distal third region risk for entrapment in some patterns

›Healing considerations

›Nonunion risk with motion and distraction

›Malunion risk with poor immobilization

Therapeutic Considerations

›Management rationale

›Nonoperative pathway common

›Functional bracing after initial splinting in many cases

›High union rates reported in orthopedic literature

›Operative indications

›Open fracture

›Vascular injury

›Floating elbow or ipsilateral forearm fracture

›Pathologic fracture

›Failure of acceptable alignment in brace

›Radial nerve palsy approach

›Primary palsy often neuropraxia with observation common

›Secondary palsy after manipulation increases concern for iatrogenic injury and prompts specialist discussion

11Patient Discharge Instructions/pdi23

Copy discharge instructions

›Home care and follow up

›Immobilization care

›Keep splint clean and dry

›Do not remove splint unless instructed

›Elevation and swelling control

›Elevate hand above heart as much as possible for 48 hours

›Ice over splint at painful area 10 to 15 minutes at a time

›Activity restrictions

›No lifting with injured arm

›Sling use as directed

›Pain plan

›Acetaminophen as directed

›Ibuprofen as directed if safe for patient

›Return to ED now

›Increasing pain not controlled with medication

›New numbness or weakness in hand

›Fingers becoming cold pale or blue

›Increasing tightness or swelling in arm or hand

›Splint too tight or causing pressure sores

›Fever or wound drainage if any wound present

›Follow up timing

›Orthopedics within 7 days

›Earlier follow up for any neurologic deficit

12References/r13

Clinical guidelines and evidence sources

›Core references

›AAOS and orthopedic trauma society guidance on humeral shaft fractures

›Nonoperative functional bracing principles

›Operative indications including open fracture and vascular injury

›ACEP clinical policy and consensus on ED procedural sedation

›Ketamine procedural sedation evidence level statements

›Propofol procedural sedation evidence level statements

›ATLS principles for initial trauma assessment

›Primary survey structure

›Secondary survey completeness

›Orthopedic trauma literature on radial nerve palsy in humeral shaft fracture

›Observation for primary palsy common

›Exploration considerations for secondary palsy or open injury

Evidence & Review

Reviewed by SymptomDx Medical Team · Last reviewed March 6, 2026

SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.