Fractures - Humerus

Disclaimer

These guidelines have been produced to guide clinical decision making for the medical, nursing and allied health staff of Perth Children’s Hospital. They are not strict protocols, and they do not replace the judgement of a senior clinician. Clinical common-sense should be applied at all times. These clinical guidelines should never be relied on as a substitute for proper assessment with respect to the particular circumstances of each case and the needs of each patient. Clinicians should also consider the local skill level available and their local area policies before following any guideline. 

Read the full CAHS Clinical disclaimer

Mechanism of injury

  • Fall or direct trauma to the proximal humerus.
  • Spiral fractures are the result of a twisting injury and may be secondary to non-accidental injury especially in children < 2 years of age.

Examination

  • Swelling and mild tenderness of the upper arm with reluctance to move.
  • Obvious deformity and shortening may be present with displaced fractures.
  • Look for weakness in thumb or wrist extension and sensory loss in the web space between thumb and index finger. 

Imaging

  • A humerus X-ray should have anteroposterior (AP) and lateral views and include the shoulder and elbow joints.

General management

For general assessment and management, see Fractures - Overview.

Specific management

Proximal Humerus Fractures

  • Younger children are prone to buckle fractures of the proximal humerus.
  • Adolescents are more likely to have Salter-Harris fractures around the physis.
  • The degree of angulation is usually not an issue. This will correct with gravity and remodelling.

Proximal humerus fractures with < 50% displacement

  • Collar and cuff with the elbow at 90 degrees and Orthopaedic Fracture clinic follow up in 1 week.

Proximal humerus fractures with > 50% displacement

  • Discuss with Orthopaedic team for further management.
A buckle fracture of proximal humerus
Buckle fracture of proximal humerus (above)
A proximal fracture with 40 degrees of angulation
Proximal humerus fracture with 40 degrees of angulation (above)
A Salter-Harris II fracture of proximal humerus
Salter-Harris II fracture of proximal humerus (above)

Shaft Fractures

  • Shaft fractures of the humerus are less common than proximal or distal (supracondylar) fractures
  • Transverse fractures generally occur from a direct blow and spiral fractures from a twisting mechanism
  • Consider non-accidental injury in younger children with spiral fractures

Shaft fractures with minimal angulation (< 10 degrees in adolescents and < 20 degrees in younger children)

  • Collar and cuff with the elbow at 90 degrees and Orthopaedic Fracture Clinic follow up in 1 week.
  • A U-slab is an alternative to protect the fracture site – discuss with Emergency Department senior doctor or Orthopaedic team if there is significant displacement.

Shaft fractures with > 10 degrees of angulation, complete displacement or radial nerve deficits

  • Discuss with Orthopaedic team for further management.
A complete fracture of shaft of humerus with mild displacement
Complete fracture of shaft of humerus with mild displacement (above)
A spiral fracture of shaft of humerus
Spiral fracture of shaft of humerus (above)
 
A completely displaced proximal humerus fracture
Completely displaced proximal humerus fracture (above)

References

  1. McRae R, Max Esser M, Practical Fracture Treatment Fifth Edition, Churchill Livingstone, 2008
  2. Rang M, Pring ME, Wenger DR. Kluwer W, Rang's Children's Fractures Fourth edition. Wolters Kluwer, 2018

Endorsed by: Nurse, Co-director, Surgical Services  Date: Feb 2022


 Review date:  Feb 2024


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