Editors

VesaSavolainen

Humeral and Forearm Fractures

Usually caused by falling, direct impact or twisting.
Conservative treatment in outpatient care is usually indicated in:
- undisplaced fractures of the greater tubercle of the humerus
- most fractures of the neck of the humerus
- minor epicondylar fractures of the humerus
- stable fractures of the head of the radius.
Other fractures are often treated operatively, and the treatment approach should be evaluated at a surgical unit.

The most common fracture of the proximal humerus (Image 1)
Occurs in adults of all age groups
The typical injury mechanism is falling on the side with direct lateral impact to the shoulder.
A common complication of shoulder dislocation
Clinical examination reveals pain, lack of active movement and tenderness on palpation of the lateral proximal humerus.
The fragment is often comminuted, and the pull exerted by the rotator cuff tendons may displace the fragment either subacromially (Images 2 3) or posteriorly (Image 4).
Displaced fractures require operative treatment.
In the case of conservative treatment
- Arm sling and pain management for 3 weeks
- Passive range-of-motion exercise after 3 weeks
- Active strength training after 6 weeks
- Repeat x-rays 1 and 6 weeks after injury
Ossification problems are rare.
Time to recovery for light loading 8-12 weeks and for physical work 12-20 weeks

A common fracture type
More common in the elderly
The typical injury mechanism is falling on the side with direct impact to the shoulder.
Clinical examination reveals pain, lack of active movement and tenderness on palpation of the proximal humerus.
Large haematomas in the upper arm and chest area are common.
On x-ray, the position of the articular surface, any displacement of the insertion sites of the rotator cuff (greater/lesser tubercle) and bone contact between the proximal humerus and the humeral diaphysis should be assessed (Image 5).
Fracture of the surgical neck of the humerus is a rather common fracture type.
A large share of the fractures are suitable for conservative treatment in outpatient care Treatment of Proximal Humeral Fractures in Adults.
Patients with comminuted, significantly displaced fractures (Image 6) should be referred without delay to the nearest surgical unit for evaluation of the treatment approach.
Conservative treatment is the same as for fractures of the greater tubercle of the humerus.
Ossification problems are rare.
Time to recovery for light loading 10-14 weeks and for physical work 16-20 weeks

A distinctly rarer injury than fracture of the proximal humerus
Occurs in adults of all age groups (Image 7)
The fracture takes a long time to heal, and ossification problems are common (about 1 in 3 fractures fail to unite).
The treatment approach should primarily be evaluated by a surgical unit.
In fractures of the humeral diaphysis, the prevalence of radial nerve injuries caused by stretching or compression is about 10%.
- Radial nerve function (extension of the wrist and fingers, skin sensation at the first web space) should therefore be checked and recorded in the patient record.
In the case of conservative treatment
- Immobilization with an individually fitted, long humeral brace for 8-16 weeks
- Collar cuff sling for 2 weeks
- Passive physical exercises of the shoulder and elbow joints as soon as permitted by pain
- Active muscle strength training as soon as the fracture has begun to consolidate and become slightly more stable (about 8-10 weeks)
- X-rays should be repeated 8, 12 and 16 weeks after the injury.
Bone union normally occurs within about 12-20 weeks.
Due to the long healing time and the need for immobilization, conservative treatment usually leads to stiffness of the shoulder and elbow joints and muscle atrophy of the injured limb.

Avulsion fractures after trauma involving twisting of the elbow joint
Fairly rare, usually seen in growing children or adolescents or young adults
A lateral epicondylar fracture is an avulsion fracture of the lateral collateral ligament (LCL), and a medial epicondylar fracture is an avulsion fracture of the medial collateral ligament (MCL).
Small (< 5 mm) avulsion fractures are treated conservatively.
- Pain management, short-term immobilization (about 1 week) with an arm sling, as necessary, and physical exercise of the elbow joint as soon as possible
Large (> 5 mm) and displaced fractures require operative treatment.
In growing children and adolescents, fractures may be large. In these patients, fractures of the medial epicondyle may be complicated by ulnar nerve entrapment.
- Ulnar nerve function should be clinically examined and recorded in the patient record.

May be unilateral involving either the medial or lateral epicondyle or bilateral (supracondylar humeral fracture).
Conservative treatment may only be considered if the intra-articular displacement of the fracture fragments does not exceed 2 mm.
The patient must be referred to an operative unit where more detailed imaging (CT) of the fracture can be done and the need for operative treatment can be evaluated.
In practice, operative treatment is often needed.

The most common fracture of the elbow region
Occurs in all age groups
A majority of the fractures are stable depressed fractures that are suited for conservative treatment in outpatient care.
Large (> 1/3 of joint surface) and/or dislocated (> 5 mm) fractures require detailed imaging (CT) and evaluation of the need for operative treatment.
In the case of conservative treatment
- Immobilization with an arm sling for 0-2 weeks (as necessary)
- Free, non-weight-bearing range-of-motion exercises of the elbow joint in weeks 2-6 after the injury
- Loading of the upper extremity and force production > 6 weeks after the injury
- Repeat x-rays 1 and 6 weeks after the injury
- Time to recovery for light loading 4-8 weeks and for physical loading 8-12 weeks

The second most common fracture of the elbow region (Image 8)
Occurs in adults of all age groups
The mechanism of injury is usually direct posterior impact to the elbow when falling.
Associated injuries are rare.
Treatment is nearly always operative.

Diaphyseal fractures of the long bones of the forearm may occur either separately or combined.
Diaphyseal fractures of individual bones (radius, ulna) usually occur as a result of a direct impact to the forearm.
Diaphyseal fractures of both bones concomitantly usually result from a twisting force affecting the mid-forearm.
As the union of tubular bones takes a long time (8-12 weeks), the treatment is nearly always operative.