SplintER Series: A Case of Arm Pain

An 80-year-old male presents with severe right arm pain after he tripped and fell down 2 steps. Examination shows deformity and swelling to his right upper arm. You obtain AP and lateral humerus x-rays as above.

1. What is your diagnosis?

A comminuted and displaced fracture of the humeral shaft with significant varus angulation.

Pearl: Humeral shaft fractures are common and account for 3% of all fractures. Even though the majority of these fractures are unstable, they typically do well with non-operative management [1,2].

2. What are the risk factors and mechanism of injury?

Patients who sustain humeral shaft fractures fall under a bimodal age distribution. Most are young patients with high-energy trauma or elderly, osteopenic patients with low-energy injuries [1]. The typical mechanisms of injury are a direct blow or a fall on an outstretched arm [2-4].

3. What physical exam findings are expected?

Patients often present with a shortened upper arm +/- deformity. Displacement is dependent on the level of the fracture. Muscle attachments of the pectoralis major and the deltoid are influencing factors for significant displacement. Complications include acute compartment syndrome and radial nerve palsy [3,4].

Pearl: The radial nerve runs along the spiral groove of the humerus and is the most commonly injured nerve with humeral shaft fractures, seen in 11.8% of cases [5,9]. More than 80% of radial nerve injuries recover spontaneously [5].

4. Which imaging modalities can be used?

Plain radiographs of the humerus in AP and lateral. Consider radiographs of joints above and below to evaluate for extension of the fracture, concomitant injuries shoulder dislocation, or forearm fractures (floating elbow) [2,3].

5. What is the management in the ED?

Immobilize with a hanging arm cast or a coaptation splint (Figures 2 and 3). The coaptation splint will start from the axilla, wrap around the elbow which should be flexed to 90 degrees, and extend over the acromion process. Utilize a valgus mold to counter the typical varus displacement. Support the wrist with a collar and cuff sling, while keeping the elbow unsupported to provide traction [4,6,8]. Review more splinting techniques here.

Figure 2: Coaptation splint. Author’s own images.

$Post-reduction humeral fracture radiograph$

Figure 3: Post-reduction radiographs of the right humerus demonstrating improved angulation. Author’s own images.

6. What is the definitive management of this injury?

Non-operative management is the mainstay of treatment for the majority of cases. Over 90% of patients have acceptable healing. Malunions with residual angulation can be well-tolerated due to the mobility of the shoulder and elbow [1-3]. The splint will be replaced in 2 weeks with a Sarmiento (functional) brace [1,4]. Surgical intervention such as plate fixation and intramedullary nailing (Figure 4) is indicated for open or comminuted fractures, vascular injury, brachial plexus injury, ipsilateral forearm fracture (floating elbow), and compartment syndrome [1,2,7].

Figure 4: Post-operative radiographs of the right humerus with intramedullary nail. (Case courtesy of Dr Sajoscha Sorrentino, Radiopaedia.org, rID: 15644)

Resources and References

Check out ALiEM’s SplintER Series to brush up on other can’t miss shoulder and arm injuries.

Walker M, Palumbo B, Badman B, Brooks J, Van Gelderen J, Mighell M. Humeral shaft fractures: a review. J Shoulder Elb Surg. 2011;20(5):833-844. PMID: 21393016
Bounds EJ, Frane N, Kok SJ. Humeral Shaft Fractures. [Updated 2020 Aug 24]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK448074/
Bookman K. Humerus and Elbow. In: Rosen’s Emergency Medicine: Concepts and Clinical Practice. 9th Ed. Elsevier; 2018:530-548.
Eiff MP, Hatch R. Humerus Fractures. In: Fracture Management for Primary Care. 3rd Ed. Elsevier; 2018:154-174.
Korompilias A V., Lykissas MG, Kostas-Agnantis IP, Vekris MD, Soucacos PN, Beris AE. Approach to radial nerve palsy caused by humerus shaft fracture: Is primary exploration necessary? Injury. 2013;44(3):323-326. PMID: 23352153
Zehms CT, Balsamo L, Dunbar R. Coaptation splinting for humeral shaft fractures in adults and children: a modified method. Am J Orthop. 2006;35(10):452-454. PMID: 17131733
Ouyang H, Xiong J, Xiang P, Cui Z, Chen L, Yu B. Plate versus intramedullary nail fixation in the treatment of humeral shaft fractures: an updated meta-analysis. J Shoulder Elb Surg. 2013;22(3):387-395. PMID: 22947239
Shantharam SS. Tips of the trade #41: Modified coaptation splint for humeral shaft fractures. Orthop Rev. 1991;20(11):1033-1039. PMID: 1749659
Venouziou AI, Dailiana ZH, Varitimidis SE, Hantes ME, Gougoulias NE, Malizos KN. Radial nerve palsy associated with humeral shaft fracture. Is the energy of trauma a prognostic factor? Injury. 2011;42(11):1289-1293. PMID: 21353219
Strohm P, et al. Humerus shaft fractures – where are we today? Acta chirurgiae orthopaedicae et traumatologiae Cechoslovaca, 2011;78(3):185-9. PMID: 21729633

Author information

Luke Lin, MD

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