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Humeral Shaft Fracture (Holstein-Lewis Pattern and Radial Nerve Injury)

Common upper extremity fracture (3 percent of all fractures) with high union rates with conservative treatment using functional bracing (Sarmiento brace); commonly classified by AO/OTA into types A (simple), B (wedge), C (complex); associated with radial nerve injury in 8–18 percent (Holstein-Lewis distal third spiral fracture pattern especially); managed with closed reduction and functional bracing as gold standard, with surgical fixation (intramedullary nailing or plating) for failed bracing, open fractures, polytrauma, brachial plexus injury, segmental fractures, and bilateral fractures.

Written by: Saygı Hospital Health Guide Editorial Board
Last updated:

This content has been compiled by the Saygı Hospital Health Guide Editorial Board and is periodically reviewed by a specialist physician.

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What is Humeral Shaft Fracture (Holstein-Lewis Pattern and Radial Nerve Injury)?

Humeral shaft fracture is a common upper extremity injury accounting for 3 percent of all fractures and 14 percent of long bone fractures. Bimodal age distribution: young men (motor vehicle accidents, falls, contact sports, industrial injury) with high-energy mechanisms, and elderly women (fall from standing on outstretched hand, fragility osteoporotic mechanism) with low-energy mechanisms. Annual incidence approximately 13 per 100,000.

Mechanism of injury: direct blow (transverse fracture or comminuted, often closed-fist or stick), indirect torsional force (spiral fracture, classic in distal third — Holstein-Lewis pattern, often from arm wrestling, throwing, fall during athletic activity), axial loading combined with bending (oblique fractures), pathologic fracture in compromised bone (metastatic, primary tumor, osteoporotic). High-energy mechanisms more often produce comminuted patterns and associated injuries.

AO/OTA classification (modern standard): 12 indicates humerus shaft. Type A — simple two-part fractures (12-A1 spiral, 12-A2 oblique >30 degrees, 12-A3 transverse <30 degrees); Type B — wedge fractures with intermediate fragment (12-B1 spiral wedge, 12-B2 bending wedge, 12-B3 fragmented wedge); Type C — complex multifragmentary fractures (12-C1 spiral, 12-C2 segmental, 12-C3 irregular). Each subtype provides prognostic information and surgical planning guidance.

Anatomic considerations: humeral shaft extends from upper border of pectoralis major insertion proximally to supracondylar ridge distally. Radial nerve runs in spiral (radial) groove along posterior humerus mid-shaft, then crosses anteriorly through lateral intermuscular septum at junction of middle and distal third — making it vulnerable to injury in distal third spiral fractures (Holstein-Lewis pattern, classically described in 1963; distal third spiral oblique fracture with proximal extension into spiral groove area). Radial nerve injury occurs in 8–18 percent of humeral shaft fractures; up to 22 percent in Holstein-Lewis pattern; majority (90 percent) are neurapraxia or axonotmesis with spontaneous recovery in 70 percent within 4–6 months; persistent radial palsy at 4–6 months warrants exploration; iatrogenic radial nerve injury can occur during open reduction and internal fixation (ORIF) — especially with anterior approach, requires meticulous identification and protection. Other neurovascular structures at risk: musculocutaneous nerve (proximal humerus injury), median nerve and brachial artery (less commonly with shaft fracture, more so with elbow region); ulnar nerve (rare with shaft, more with distal humerus).

Symptoms

Pain, swelling, and deformity of upper arm after trauma
Inability to use the affected arm
Visible angulation or shortening of upper arm
Crepitus on gentle palpation
Wrist drop (radial nerve palsy with weakness of wrist and finger extension at MCP)
Numbness in dorsal first web space (radial nerve sensory)
Bruising and ecchymosis along upper arm
Open wound with visible bone or bleeding (open fracture)
Distal extremity vascular compromise (rare but emergent — assess pulses, capillary refill, color)
Brachial plexus signs (upper trunk weakness, sensory loss)
Bilateral arm involvement (motor vehicle accident with bilateral injuries)
Pathologic fracture without significant trauma (suspect metastasis or primary bone tumor)

Risk Factors

High-energy trauma (motor vehicle accident, fall from height, contact sports)
Low-energy fall on outstretched hand (especially elderly osteoporotic)
Osteoporosis (postmenopausal women, fragility fracture)
Age >65 years (decreased bone density)
Pre-existing bone disease (Paget, fibrous dysplasia, metastasis, primary tumor — pathologic fracture)
Smoking (impaired healing)
Diabetes (increased complications)
Sports requiring throwing or arm wrestling (Holstein-Lewis spiral fracture)
Industrial occupational exposure
Chronic corticosteroid use (osteoporotic fragility)
Vitamin D deficiency
Polytrauma with multiple injuries

When to See a Doctor?

If you experience any of the following symptoms, seek medical attention promptly:

  • Upper arm pain and inability to use arm after trauma — emergency department
  • Open fracture or visible deformity — emergent
  • Wrist drop or hand sensory loss after arm injury (radial nerve palsy — emergent assessment)
  • Distal extremity vascular compromise (pale, cool, pulseless hand) — emergent
  • Bilateral arm fractures or polytrauma — multidisciplinary trauma assessment
  • Pathologic fracture without significant trauma (oncology workup)
  • Failed conservative management with delayed union (no callus by 12 weeks) or nonunion (no callus by 6 months)
  • New radial nerve palsy after fracture treatment or reduction (iatrogenic — emergent)
  • Persistent pain, deformity, or functional impairment after presumed minor injury
  • Failed brace tolerance (severe pain, skin breakdown, functional inability to maintain brace)
  • Late symptomatic malunion or nonunion for revision surgery
  • Suspected complication (infection, hardware failure, nerve injury)

Treatment Methods

01
Initial assessment (emergency department): comprehensive history (mechanism, hand dominance, occupation, comorbidities, anticoagulant use, prior arm injury, polytrauma assessment), thorough physical examination including detailed neurovascular assessment (radial nerve — wrist extension, MCP extension of fingers, thumb extension and abduction; median nerve — wrist flexion, finger flexion, thumb opposition; ulnar nerve — finger abduction-adduction, sensation in ring-little fingers; brachial artery and ulnar artery pulses, capillary refill, color, temperature), examination of shoulder and elbow joints, assessment of skin condition for open fracture or significant compromise, evaluation for compartment syndrome (rare in arm but possible), associated injuries in polytrauma
02
Imaging: AP and lateral radiographs of humerus (full length including shoulder and elbow joints — assesses fracture pattern, displacement, angulation, comminution, location relative to spiral groove and radial nerve, presence of pathologic features), include orthogonal views (true AP and true lateral with patient repositioning rather than tube angulation to maintain orthogonal views); CT rarely needed for shaft fractures but useful for complex periarticular extensions; bone scan or skeletal survey if pathologic fracture suspected
03
Closed reduction and functional bracing (gold standard for closed humeral shaft fractures): initial application of coaptation U-splint or hanging arm cast for 7–14 days for swelling subsidence and pain control, then transition to functional Sarmiento brace (clamshell circumferential brace, custom-molded or off-the-shelf, with humeral shaft contoured to allow elbow flexion-extension and shoulder motion); allows fracture healing through controlled functional weight-bearing of arm hanging in gravity (gravity creates traction force on fracture, with brace providing circumferential constraint to limit angular displacement)
04
Acceptable alignment criteria for non-operative management: <20 degrees anterior angulation, <30 degrees varus angulation, <3 cm shortening (some authors more strict criteria — <15 degrees angulation in any plane, <2 cm shortening); minimal acceptable rotational malalignment (<25 degrees difference); functional outcome generally excellent even with mild malunion due to spherical motion of shoulder and elbow accommodating malunion
05
Bracing technique and follow-up: instruct patient on proper brace use (worn 24/7 except brief hygiene removal, tightened twice daily, allow active elbow and shoulder range of motion in brace, maintain arm at side, do not lift heavy objects, do not bear weight on arm), serial radiographs (1, 3, 6, 12 weeks then monthly) to monitor reduction maintenance, alignment, and progressive callus formation; expect union by 12–16 weeks; brace continued until clinical and radiographic union; gradual return to full function thereafter
06
Surgical indications: open fractures (Gustilo-Anderson grade I–III), segmental fractures, bilateral humeral fractures, polytrauma requiring early upper extremity weight-bearing (use of crutches), ipsilateral forearm fracture creating 'floating elbow' (combined humeral shaft and forearm fracture — both should be fixed), neurovascular injury requiring exploration, pathologic fractures (typically need surgical stabilization with adjunctive radiation-chemotherapy for tumor), brachial plexus injury, failed conservative management with delayed union or established nonunion, severe obesity making brace ineffective, patient inability to comply with bracing protocol, intra-articular extension into elbow or shoulder, multiple injuries requiring early mobilization
07
Surgical options: (1) Intramedullary (IM) nailing — antegrade (rotator cuff splitting approach through proximal humerus) or retrograde (posterior elbow approach) nail insertion, closed or limited open technique, advantages include preservation of fracture biology, minimal soft tissue dissection, good for diaphyseal fractures, suitable for pathologic fractures (allows prophylactic fixation of full length); disadvantages — risk of rotator cuff impingement (antegrade), higher nonunion rate than plating, may not be suitable for proximal or distal third fractures with metaphyseal extension; (2) Plate fixation — through anterior brachialis-splitting approach (preserves musculocutaneous and radial nerves, suitable for most patterns) or posterior triceps-splitting approach (good for distal third fractures, allows direct radial nerve identification and protection); plate types include standard compression plate, locking compression plate, anatomic plates; advantages — direct fracture reduction with anatomic fixation, lower nonunion rate, useful for any pattern; disadvantages — larger soft tissue dissection, risk of iatrogenic radial nerve injury; (3) External fixation — rarely used, reserved for severely contaminated open fractures with significant soft tissue loss as temporary stabilization before definitive fixation
08
Radial nerve injury management: assess at presentation (motor — wrist extension, MCP extension, thumb extension; sensory — dorsal first web space); for fracture-associated radial nerve palsy, observe for 3–6 months for spontaneous recovery (most are neurapraxia or axonotmesis with 70 percent full recovery); EMG/NCS at 4–6 weeks (fibrillations, denervation potentials confirm axonotmesis); persistent palsy beyond 4–6 months without recovery — exploration with neurolysis if neurapraxia, neurorraphy if rupture, nerve grafting if defect; iatrogenic radial nerve palsy after surgery — early exploration; early exploration also indicated for radial nerve palsy after closed reduction (suggesting nerve interposition) or after open fracture (typically explored at debridement)
09
Special situations: open fracture — emergent debridement, lavage, antibiotics (cefazolin or amoxicillin-clavulanate, add gentamicin for grade III), tetanus, often staged definitive fixation (external fixation or temporary stabilization initially, then definitive nailing or plating after wound stabilization, possibly antibiotic-impregnated cement spacer); pathologic fracture — orthopedic oncology consultation, biopsy if not previously diagnosed, radiation-chemotherapy as appropriate, prophylactic IM nailing through full length humerus to prevent further fracture; bilateral humeral fractures — early surgical fixation generally indicated for early mobilization; ipsilateral forearm fracture (floating elbow) — surgical fixation of both
10
Post-operative management for surgical fixation: depends on construct stability — generally early shoulder and elbow motion encouraged, gradual progressive weight-bearing as tolerated; for stable fixation may begin immediate active range of motion, light activities at 4–6 weeks, return to normal activities at 8–12 weeks; serial radiographs to monitor healing; physical therapy for shoulder and elbow range of motion, hand and wrist intrinsic strengthening
11
Complications and long-term: non-union (5–15 percent rate, higher with surgical fixation than bracing — 8–15 percent vs 2–5 percent; treated with revision plating, autograft bone grafting, possibly biologic adjuvants like BMP-7); malunion; infection (especially after open fracture or surgery); iatrogenic radial nerve palsy after surgery (manage as outlined above); shoulder or elbow stiffness; chronic regional pain syndrome (CRPS); hardware failure; need for hardware removal if symptomatic; long-term shoulder or elbow pain; rotator cuff impingement after antegrade IM nailing; functional outcomes generally excellent with appropriate management
12
Long-term: structured rehabilitation with physical therapy (range of motion, strengthening, proprioception, return to activities), gradual return to functional activities and work at 3–6 months depending on healing and occupation, lifelong attention to osteoporosis if applicable (DEXA scan, supplementation with calcium and vitamin D, bisphosphonate therapy as indicated), patient education on activity modification, multidisciplinary care including osteoporosis specialist, oncology if pathologic fracture, hand surgery for chronic radial palsy with tendon transfers if no recovery

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