A Single-Provider Technique for the Closed Reduction of Humeral Shaft Fractures

Research Article

Austin Orthop. 2018; 3(1): 1006.

A Single-Provider Technique for the Closed Reduction of Humeral Shaft Fractures

Matthew Martell DO¹, Cristin John Matthew DO¹, Gus Katsigiorgis DO¹, Muzaffar Ali BS²*

¹Northwell Health, Orthopedics, USA

²New York Institute of Technology College of Osteopathic Medicine, USA

*Corresponding author: Muzaffar Ali BS, New York Institute of Technology College of Osteopathic Medicine, USA

Received: February 28, 2018; Accepted: March 27, 2018; Published: April 03, 2018


Humeral shaft fractures (HSFs) account for approximately three percent of all fractures and 20% of all fractures in the humerus [1]. In the elderly population, the mechanism of injury is usually related to a low energy fall from standing height, whereas in younger populations, the injury results from high energy mechanisms. Given the multitude of muscular attachments along the humeral shaft, there are numerous deforming forces which must be overcome during closed reduction in order to achieve and maintain acceptable alignment of the fracture. In addition, the application of a coaptation splint to immobilize humeral shaft fractures can be a daunting task, especially for a single provider. Here we introduce a single-provider technique utilizing traction and ligament taxis to achieve closed reduction and coaptation splinting of humeral shaft fractures which can be performed by a single caregiver, without the need for multiple assistants and repeated reduction attempts.

Keywords: Humeral Shaft Fractures; Injury; Fractures


Humeral shaft fractures (HSFs) account for approximately three percent of all fractures and 20% of all fractures in the humerus [1]. HSFs exhibit a bimodal distribution, with the first peak occurring in males in their third decade secondary high energy trauma, and the second peak in females in their seventh decade resulting from low velocity falls from standing height [2-3]. Depending on the fracture morphology, HSFs can be managed effectively by both non-operative and operative techniques. Reductions of spiral fractures tend to be more stable and provide a higher rate of union due to increased surface area. Contrary to this, transverse fractures present as more difficult and unstable reductions due to the decreased surface area and multiple deforming forces from various muscle attachments. In recent decades, closed reduction and immobilization in a hanging arm cast, coaptation splint or functional fracture brace has demonstrated union rates of approximately 90% [4-6].

This modality of treatment is dependent on callus formation and secondary bone healing due to the lack of rigid stabilization. Successful non-operative management with good functional range of motion can be seen when the reduction meets certain radiographic criteria: < 20 degrees of sagittal angulation, < 30 degrees of varus/valgus angulation and limb shortening <2-3 cm [1]. Favorable outcomes in these fractures with non-operative management are due to greater tolerance of angulation in the humerus as compared to other long bones. The downside of non-operative treatment is that it requires a long period of immobilization, which carries a risk of prolonged shoulder and elbow joint stiffness and patient inconvenience. This can be problematic in the non-compliant patient. Non-union following conservative treatment of these fractures has been seen in 10-20% of cases, which then necessitates surgical management [6,7].

In addition to non-union, other indications for operative treatment include open fractures, segmental fractures, pathologic fractures, fractures associated with vascular injuries, bilateral humerus fractures, poly-trauma, presence of radial nerve palsy after fracture manipulation, neurologic loss after penetrating injuries, fractures with unacceptable alignment and failure of conservative treatment. Surgical options include external fixation, open reduction and internal fixation, minimally invasive percutaneous osteosynthesis, and antegrade or retrograde intramedullary nailing. Each of these techniques has their own advantages and disadvantages, and the rate of fracture union may vary based on the technique used. A relatively high incidence of radial nerve injury has been reported with surgical management of humeral shaft fractures.


The humeral shaft serves as the site of origin for numerous muscles in the brachium, including the brachialis, brachioradialis, and the medial and lateral heads of the triceps brachii. The deltoid, pectoralis major, teres major, latissimus dorsi, and coracobrachialis also insert onto the humeral shaft. The location of the fracture along the humeral shaft in relation to these sites of muscle attachment determines the deformity seen in HSFs. Fractures distal to the deltoid insertion will have the proximal fragment abducted by the pull of the deltoid, while the distal fragment is pulled medially by the triceps and biceps. In contrast, fractures proximal to the deltoid insertion will have the proximal fragment adducted by the pull of the pectoralis major and latissimus dorsi.

Of all the neurovascular structures that span the length of the humerus, the radial nerve is the most intimately associated with the humeral shaft. The radial nerve enters the posterior compartment of the brachium after entering the triangular interval. Here the nerve courses along the humeral shaft in the spiral groove, and can be found approximately 14cm proximal to the lateral epicondyle and 20cm proximal to the medial epicondyle.8 The nerve then exits through the lateral intermuscular septum distally at least 7.5cm proximal to the distal articular surface of the humerus [9]. It is here where the radial nerve is tightly tethered to the humeral shaft that it is susceptible to traction injuries [8]. The nerve then runs anteriorly over the lateral epicondyle, passing between the brachioradialis and brachialis to continue on into the forearm.

Current Methods of Non-Operative Management

After performing a closed reduction, HSFs are generally immobilized in either a coaptation splint or a hanging arm cast. Hanging arm casts rely on the longitudinal traction provided by the weight of the arm and cast while the patient’s wrist is suspended by a sling. The cast however can be overly constrictive and should generally be avoided in patients with significant soft tissue swelling, which can result in ischemic injury to the extremity. The coaptation splint should wrap around the elbow extending up the lateral portion of the upper arm and drape over the shoulder, extending just past the acromioclavicular joint. Both of these methods routinely require multiple providers or assistants to obtain an adequate reduction and appropriately apply the cast or splint. With adequate reduction and immobilization, follow-up is generally initiated on a weekly or biweekly basis until radiographic and clinical union has occurred, typical occurring between 8 and 14 weeks.

Functional fracture bracing is the preferred definitive treatment for humeral shaft fractures [3-5]. After the acute soft tissue swelling and fracture mobility have subsided, generally one to two weeks after initial reduction and immobilization, a functional brace can be applied. Sarmiento et al, pioneered the use of the functional fracture brace in humeral shaft fractures. In their relatively large study of 620 patients, they saw union rates of 97% and high patient satisfaction scores with functional bracing [4]. Weekly follow-up for tightening of the brace with serial radiographs is recommended to ensure adequate healing and acceptable appropriate fracture alignment.

Single-Provider Reduction Technique

Longitudinal traction of the arm is key to performing a closed reduction of the humeral shaft. We therefore recommend the use of a stretcher that can seat the patient upright to allow the humerus to be perpendicular to the floor, as well as a Mayo stand or equivalent rolling table. Other supplies necessary to perform this technique are shown in (Figure 1a & 1b).