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Humerus Fracture Physiotherapy
A humerus (or humeral) fracture is refers to a break in the bone
of the upper arm. The humerus bone is the long bone that is located between the
shoulder and the elbow.
Humeral fractures can be categorized into three type of groups, depending on
which part of the bone is broken. A proximal humerus fracture is when
the humerus bone is broken at or near the top, near or at the shoulder.
humeral fractures, however, which are also known as
- humeral shaft fracture or
- diaphyseal humerus
refer to a break somewhere in the middle section of the bone.
Distal humerus fractures are where the humerus bone is broken the furthest away, nearer the elbow.
About 3 - 5% of all broken bones are midshaft humeral fractures and these kind of fractures tend to
- young males (20-30’s) who have experienced a high-energy or high-impact type of injury
- elderly females (60-70’s) with low-energy or low-impact type of injuries
Humeral Shaft Anatomy and review
So the mid-shaft region of the humerus is the long, thin part of the
The higher top part is cylindrical in shape and as it goes downwards closer and closer towards
the elbow it becomes narrower and more prism shaped. The back surface of
the shaft of humerus is bigger than the front part of the bone.
The shaft of humerus can be divided into three (3) thirds:
- the proximal (upper) third
- middle (mid) third and
- distal (lower) third
what are the Common Causes of Midshaft Humerus Fractures
Most of the time, midshaft humerus fractures are usually the result of:
- A Fall / Falls:
the most common cause of a midshaft humeral fracture, particularly in
the elderly, is a simple fall. Occasionally it may be caused by falling
onto an outstretched hand when the arm is abducted – out to the side
- Direct Forces And Blows: high energy force such as in sports injuries and motor vehicle accidents that affect the upper arm often causes a transverse fracture
- Torsion (Rotational) Forces:
Forceful twisting of the upper arm can lead to a long-ish spiral fracture of the humerus. Long,
spiral humeral fractures in children should be carefully examined as
they may indicate child abuse, neglect and social issues
- Bone Disease: Metastatic breast cancer can cause spontaneous fractures in the middle of the humerus "just like that"
categorization of Humerus Fractures
Midshaft humeral fractures can be classified into different types
depending on the location and direction of the break and the associated
- Proximal Third: 30% of humeral fractures occur in the top third region
- Middle Third: 60% of mid shaft humerus fractures occur in the middle portion (this article is about mid shaft humeral fractures)
- Distal Third: 10% of humeral shaft fracture occur in the lower third
2. Fracture Pattern
- Transverse Fracture: Where the line of the fracture runs perpendicular to the bone shaft i.e. horizontally in the humerus (like a straight fracture across the humerus)
- Oblique Fracture: where the fracture line is angled
- Spiral Fracture: where there is a spiral-shaped fracture line usually due to twisting of the bone, it's a fracture that seems to "go around the bone"
- Comminuted Fracture: where the bone breaks into several pieces / fragments
- Segmental Fracture: Where there are at least two fracture lines that together isolate a section of bone
3. Degree of Displacement
A displaced humeral fracture happens when the fractured humeral bone fragments of the shaft
do not line up normally. A non-displaced fracture is where normal
alignment is maintained despite the fracture line.
4. Soft Tissue Damage
- Open Fractures: Open fractures happen when the
broken bone puncturing through the skin from the inside (note that it could
also be from a blow to the shoulder that cuts through the skin and muscle).
Around 3-10% of humeral shaft fractures are open fractures.
- Closed Fractures: Most humeral fractures are closed fractures, where the skin remains unbroken.
5. Pathological Fracture
This type of fracture is where the bone has broken due to a disease
that has weakened the bone such as metastases and cancer. When it's pathological
fractures, there may not have a specific incident that had directly caused the
injury, the midshaft humerus fracture may have occurred spontaneously (yeah that can happen and does happen).
Symptoms of Midshaft Humeral Fracture
Whichever part of the bone is broken, a midshaft humerus fracture will typically cause:
There is usually instantaneous severe, ongoing pain associated with the
fracture. Patients WILL know that they had hurt themselves badly, and
potentially fractured their bone
- Restricted Arm Movement:
Shoulder and arm movement will have a lot of pain so typically patients with a
midshaft humerus fracture will definitely be protective and often unwilling to move their arm. There
will be associated weakness throughout the whole arm including the wrist and hand
- Swelling And Bruising:
There will be significant swelling and bruising in the upper arm which
may travel and go all the way down to the hand. The swelling normally comes on
fairly fast and this is due to extensive soft tissue damage and bleeding in the surrounding
- Bony Sounds and Sensations (Crepitus): Patients will be alarmed of the grinding, grating sound and sensation when the fractured pieces rub against each other directly
- Obvious Fracture Deformity:
If the midshaft humeral fracture is displaced (moved), there may be an obvious deformity of the
upper arm or looking abnormal e.g. the arm may appear shorter than normal if the bone at the
fracture site has overlapped
- Bleeding: If the humeral fracture is an open fracture where the bone has pierced through the skin, there will be bleeding (or if the blow or force split the skin and soft tissue).
- Altered Sensation:
If there is nerve damage associated with the humerus fracture, then
there may be altered sensation such as pins and needles or numbness
at and below the fracture site. Normal movement at the wrist and hand may also
be affected (motor aspect of the nerve can be injured. Unfortunately radial nerve damage is fairly common with humeral shaft fractures =(
Diagnosing Humeral Shaft Fractures
Sometimes, midshaft humeral fractures can be very obvious especially when there is obvious fracture deformity. However in many of them, the attending doctor will need to confirm these fractures with imaging.
If you doctor suspects a midshaft humerus fracture you will be sent
X-rays will be taken in different directions, usually from
- front to back (AP) and
- from the side (lateral)
and both the shoulder
and elbow joints should be evaluated for any damage.
the doctor to see where the fracture is, what type of fracture it is,
any associated damage and the severity of the injury so that they can
plan the best course of treatment.
what are the common Treatments of Midshaft Humerus Fractures
Treatment for humerus fractures will vary a little depending on the
location and severity of the fracture, but good news is that in most cases, surgery is not
required. Approximately 90% of humeral shaft fractures unite (heal)
without the need for surgery, and just with shoulder humeral physiotherapy.
Non-surgical treatment for a midshaft humerus fracture usually consists of:
The first 4 weeks patients will have to protect and immobilize the humeral midshaft fracture to allow:
- fracture to start to form
- swelling and pain to subside
Humeral shaft fractures are typically treated with a coaptation splint
that extends from the shoulder and extends all the way to the forearm, and at the same time, it holds the elbow in 90
In some cases, you may also be additionally given a collar and cuff sling to
support the arm.
Please understand that it is really important to
let the arm hang by your side
without any support through the elbow as this allows gravity to help
realign the fracture (often patients try to "support" the fracture by
tightening their biceps and/or elbow but that's not the right way to
encourage humeral fracture healing).
If there is any pressure through the elbow it
pushes the bones together resulting in them healing in the wrong
After two to three weeks the coaptation is switched for a functional
brace or a cylindrical brace that fits around the upper arm
holding the humerus in place. It leaves the shoulder and elbow free to
move which helps prevent stiffness.
You will be prescribed painkillers and anti-inflammatories. If
you have an open fracture you will be given additional antibiotics to
reduce risk of infection.
Our senior physiotherapists will partner with you and work together with you through a shoulder physiotherapy program
with you after your midshaft humeral fracture.
We will help you get started with active exercises for the elbow,
wrist and hand to prevent
stiffness and weakness from developing and it is usually fine to take
your arm out of your sling to do these exercises.
orthopedic doctor had determined that your humeral fracture has started
to unite, they'd let us know and we will get you started on shoulder
mobility exercises. - we usually start shoulder exercises with very safe
pendulum exercises where patients use gravity to
move the arm, and active assisted exercises where you use your good arm
to support and move the broken arm.
After just a few weeks we
will be able to progress you with progressive strengthening exercises
and more advanced range of motion exercises.
Hey, do note that it is very, very important to stick with the shoulder physiotherapy program with us and to do your
shoulder exercises every day until you have regained full
at the shoulder, elbow and hand.
...because if you stop too soon, or
only do your exercises sporadically you are likely to have ongoing
limitations in the mobility, strength and function of your arm.
Around 10% of humeral shaft fractures with require surgical treatment.
If the bone fragments have moved or are displaced, then the broken
need to be realigned and held in place. This process is typically known
as "ORIF", which stands for open reduction internal fixation (
Most of the time, the humeral fracture is secured
shaft fractures that require surgery are usually treated with a large
metal plate that are securely held in place by screws.
- Pros: Highest success rate for surgical treatment of humerus fractures
- Cons: Higher risk of nerve damage and non-union than non-surgical treatment
Intramedullary (IM) Rods
In some cases a
humerus fracture will treated surgically with an intramedullary
rod/nail. This is when a long metal rod is placed down the middle of the
bone. IM nails can be used to stabilise a humerus fracture that is
between 2cm below the surgical neck and 3 cm above the elbow.
- Pros: Less invasive and less chance of nerve damage.
- Cons: Lower healing rate and higher rate of non-union.
These implants are designed to hold the bones together while the fractured parts heal – and patients should expect full union to be achieved.
Metal implants are not meant to be a long term
solution and they tend to need to be removed. If the bones fail to unite, then there is a high chance
that the implant will at some point fail and further surgery may be
The usual indications for treating a midshaft humerus fracture surgically are:
- If The Humeral Fracture Can’t Be Reduced / Aligned:
In some cases, it may be difficult to realign the bones, or maintain
the realigned position. This is usually due to associated soft tissue
injuries, head injuries, secondary injuries or patient obesity
- Open Fractures And Bleeding: If the bone has shifted enough to pierce and puncture the skin it is unlikely that the bone will realign without surgery, and it is likely severe enough to warrant immediately corrective surgery
- Segmental Fractures: If the fracture has caused a fragment of bone to break off, it will often need to be secured surgically
- Multiple Fractures:
If the humerus has broken into 4 or more pieces, or if both the left and
right upper arms are broken, or there is a break in one of the forearm
bones on the same side then surgery is usually necessary
- Vascular Damage: If there is significant vascular damage then surgery will be required
- Nerve Damage:
If the brachial plexus has been damaged then surgery is usually
necessary. If the radial nerve has been damaged, it does not usually
require surgical intervention unless there are associated injuries – the
radial nerve damage will most likely heal within 3-4 months without the
need for surgery
If after a few weeks the humeral shaft fracture has failed to heal and
the bones haven’t united then surgery may be necessary to stabilise the
- Skin or Soft Tissue Damage:
If the skin or soft tissues of the upper arm have been damaged to the
extent that it is not possible to wear a splint, e.g. severe burns, then
surgery may be required
Over 90% of humerus fractures treated non-operatively will unite and
are usually fully healed (complete union) within 8-12 weeks. Though older
patients may not regain full 100% shoulder movement, but they usually regain
enough functional range for their day to day activities (we will always aim for 100% of course)
Complications are more common with complex fractures and those requiring surgery, orthopedic surgeons will tend to be more conservative and try to prevent unnecessary surgeries,
fractures may heal with slight angulation i.e. even though healing may not be completely straight,
but this doesn’t usually cause any functional issues as the shoulder
and elbow accommodate.
Complications of Midshaft Fractures
At The Time Of Injury
is often associated damage to the surrounding nerves with midshaft
humerus fractures (such as in radial nerve damage).
The most commonly damaged nerve is the radial nerve,
as the nerve wraps around the back of the humerus, with between 8-15% of
midshaft fractures resulting in radial nerve damage.
Injury to the
radial nerve usually occurs at the time of injury, but can also occur
when the fracture is reduced so great care should be taken when
realigning the bones too.
Blood Vessel Damage
There may be damage (or risk of damage) to the brachial artery
- Frozen Shoulder - This is when the capsule of the shoulder joint becomes inflamed and
thickened typically due to lack of shoulder movement after a shoulder
- Myositis Ossificans - This is where calcification develops in the surrounding muscles.
Myositis ossificans is usually caused by returning to activities too
quickly after a midshaft humerus fracture
- Fracture Angulation - Often the bone heals at a slight angle but it rarely has any function impact and is usually not visibly noticeable
- Mal-Union or Non-Union - Mal-union is when the bone fragments unite significantly out of normal
alignment. Non-union is where the bone fragments fail to unite back
together – this is rare with a midshaft humerus fracture occurring in
only 4% of cases and tends to occur with a proximal third midshaft
fracture or spiral humerus fracture.
shoulder humeral fracture physiotherapy
Patients may also receive the following physiotherapy treatment modalities:
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