(Also known as Fractured Humerus, Humerus Fracture, Broken Arm)
What is a humeral fracture?
A humeral fracture is a condition characterized by a break in the upper arm bone (humerus) (figure 1).
The long bone of the upper arm is known as the humerus. The humerus joins with the shoulder blade to form the shoulder joint and the bones of the forearm (radius and ulna) to form the elbow (figure 1).
Figure 1 – Relevant Anatomy for a Humeral Fracture
Following a fall onto the shoulder or outstretched arm, or, due to a direct impact to the upper arm, stress is placed on the humerus. If these forces are beyond what the humerus can withstand, a break in the bone may occur. When this occurs the condition is known as a humeral fracture and can vary from a small undisplaced fracture to a severe, displaced (and/or comminuted i.e. fragmented) fracture with obvious deformity.There are generally three different regions where humeral fractures may occur:
- Near the shoulder (i.e. fracture of the neck of the humerus, fracture of the greater tuberosity)
- The shaft of the humerus
- Near the elbow (supracondylar fracture, fractures of the condyles, fractures of the epicondyles)
Humeral fractures account for approximately 4 – 5% of all fractures and are most common in patients greater than 50 years of age.
Causes of a humeral fracture
A humeral fracture usually occurs following a fall onto an outstretched hand, the elbow, or the point of the shoulder (e.g. a fall from a height, in horse riding, or whilst cycling), occasionally they may occur due to a direct blow such as a motor vehicle accident or collision with another player during contact sports such as rugby or football (e.g. a ‘hip & shoulder’ bump). In a small percentage of patients, other less common conditions such as metastatic bone disease or osteoporosis (that weaken the bone) may be present increasing the likelihood of the condition occurring. In rare cases, a humeral stress fracture can sometimes occur in overhead throwing athletes, weightlifters, gymnasts or rowers, typically due to overuse and usually in combination with inappropriate training technique or activity.
Signs and symptoms of a humeral fracture
Patients with a humeral fracture typically experience a sudden onset of sharp, intense pain at the time of injury that may cause an inability to move the shoulder and arm. Pain is usually located somewhere between the elbow and shoulder. Pain may increase when attempting to perform movements of the upper limb such as arm elevation, reaching out, overhead activities, taking the arm across the chest or during pushing, pulling, carrying or lifting activities. Pain may also increase when lying on the affected side, applying pressure to the shoulder or elbow, or on firmly touching the humerus at the site of injury. An ache in the upper arm may also be present that is particularly prominent at night or first thing in the morning (especially during the first few days following injury). Occasionally pins and needles or numbness may also be experienced in the upper arm, forearm, hand or fingers.
Patients with this condition may have noticed an audible sound at the time of injury such as a ‘click’, ‘pop’ or ‘snap’. A grinding sensation may also be present during movement of the arm and shoulder (due to bony ends rubbing against each other). There is usually localized tenderness and swelling at the site of injury (that may track further down the arm), and, depending on the severity, a bony deformity may be evident. After a day or two following injury, extensive bruising may be evident in the upper arm, or sometimes down into the elbow and/or forearm.
Diagnosis of a humeral fracture
A thorough subjective and objective examination from a physiotherapist is important to assist with diagnosis of a humeral fracture. An X-ray is required to confirm diagnosis and should always be taken if a fracture is suspected clinically. Further investigation such as CT scan or MRI might be indicated, in some cases, to confirm diagnosis and determine involvement of other structures.
Treatment for a humeral fracture
Prognosis of a humeral fracture
Most patients with a humeral fracture usually make a full recovery with appropriate management (whether surgical or conservative). Return to activity or sport can usually take place in a number of weeks to many months (depending on the forces involved in the activity and the injury severity) and should be guided by the treating physiotherapist and specialist.
In general, union (the initial healing) of a humeral fracture (i.e. whereby soft tissue called callus bridges the fracture giving it stability) typically occurs in approximately 6 – 12 weeks. Following union, the callus is gradually replaced with bone, with the majority of fracture strength achieved by 10 – 12 months and full fracture strength achieved around 1 – 2 years following injury. In patients with severe injuries involving damage to other bones, soft tissue, nerves or blood vessels, recovery time may be significantly prolonged with long term prognosis significantly affected (particularly in the elderly). In patients with only very minor fractures that are un-displaced (such as an avulsion fracture) return to sport can sometimes occur in as little as 6 – 8 weeks as guided by the treating physiotherapist.
Physiotherapy for a humeral fracture
Other intervention for a humeral fracture
Exercises for a humeral fracture
The following exercises are commonly prescribed to patients with a humeral fracture following confirmation that pain free mobilisation can commence as guided by the orthopaedic specialist, doctor or physiotherapist. You should discuss the suitability of these exercises with your physiotherapist prior to beginning them. Generally, they should be performed 3 times daily and only provided they do not cause or increase symptoms.
Your physiotherapist can advise when it is appropriate to begin the initial exercises and eventually progress to the intermediate, advanced and other exercises. As a general rule, addition of exercises or progression to more advanced exercises should take place only provided there is no increase in symptoms.
In many cases, these initial exercises may begin within 1 – 2 weeks following injury as guided by the treating physiotherapist and provided there is no increase in pain due to the exercises. Exercises involving uninvolved joints below the fracture level such as the wrist and hand (and in some cases, the elbow), can usually commence within the first 1 – 2 days following injury as guided by the treating physiotherapist.
Hand Open and Close
Curl your fingers and thumb making a tight fist then straighten your fingers as far as possible provided the exercise is pain free (figure 2). Perform this exercise in a position of comfort (this may be in a sling or collar and cuff) and repeat 10 times provided there is no increase in symptoms.
Figure 2 – Hand Open and Close (right hand)
Wrist Flexion to Extension
Begin this exercise in a position of comfort (this may be in a sling or collar and cuff) or sometimes with your forearm supported by a table, bench, or pillow etc. Bend your wrist forwards and backwards as far as you can go without pain and provided you feel no more than a mild to moderate stretch (figure 3). Repeat 10 times provided there is no increase in symptoms.
Figure 3 – Wrist Flexion to Extension (right side)
Elbow Bend to Straighten
Please note that for those fractures located close to the elbow, this exercise may not be appropriate for a number of weeks as guided by the treating physiotherapist.
For those fractures that do not involve the elbow (i.e. fractures of the upper aspect of the humerus), it may be appropriate to begin this exercise within the first few days following injury as guided by the treating physiotherapist. Begin this exercise in a position of comfort (usually beginning with your forearm and palm on your chest). Slowly, bend and straighten your elbow as far as you can go (aiming to slide your palm down your body towards the front of your thigh and then back to your chest) provided there is no increase in symptoms (figure 4). Repeat 10 times provided the exercise is pain free.
Figure 4 – Elbow Bend to Straighten (left side)
Rehabilitation Protocol for a Humeral Fracture
Some of the most commonly recommended products by physiotherapists to hasten healing and speed recovery in patients with a humeral fracture include:
- Shoulder Supports
- Ice Packs or Heat Packs
- Sports Tape (for protective taping)
- Posture Supports
- Resistance Band (for strengthening exercises)
- TENS Machines (for pain relief)
- Therapeutic Pillows
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- Shoulder Stretches.
- Shoulder Strengthening Exercises.
- Scapula Stability Exercises.
- Rotator Cuff Strengthening Exercises.
- Elbow Stretches.
- Elbow Strengthening Exercises.
- Arm Strengthening Exercises.
- Upper Body Machine Weights.
- Cable Exercises (Back & Biceps).
- Cable Exercises (Chest & Shoulders).
- Free Weights (Back & Biceps).
- Free Weights (Chest & Shoulders).
- Cardiovascular Exercise.
- Postural Taping.
- Shoulder Taping.
- Ice or Heat.
- The R.I.C.E. Regime.
- Injury Prevention.
- Understanding Pain
- Returning to Sport.
- Shoulder Diagnosis Guide.
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A humeral fracture is a condition characterised by a break in the upper arm bone (humerus). They often occur due to a fall onto the shoulder, an outstretched arm or direct trauma and typically account for approximately 4 – 5 % of all fractures. Following appropriate fracture management, assessment and treatment by a physiotherapist is vital for an optimal outcome.
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