Outline:
Fracture of humeral shaft is a kind of fracture of tubular bone, which usually occurs at the site 1 cm below surgical neck of humerus to the site 2 cm above humeral condylus. It is commonly seen in adults. The fractures in the upper and middle one-third are often caused by direct violent forces, and are mostly transverse or comminuted. In the fractures of the upper one-third (above the insertion of deltoid muscle), the proximal end is likely to displace forward and inward due to the contraction of pectoral major muscle, latissimus muscle and teres major muscle; while the distal end is likely to displace upward and outward due to contraction of deltoid muscle, coracobrachial muscle, brachial biceps and triceps muscles.

In the fractures of the middle one-third (below the end point of deltoid muscle), the proximal end is likely to displace forward and outward because of the contraction of deltoid and coracobrachial muscles; while the distal end is likely to displace upward because of contraction of brachial biceps and triceps muscles (see Fig. 7). Fractures in the lower one-third are often caused by indirect violent force (such as throwing or falling), and are mostly oblique or spiral, and with angulation or intorsion displacement. Fractures in the middle and lower one-third shaft are likely complicated by radial nerve injury.

Major points for diagnosis
1. There is a typical traumatic history of upper arm.
2. There are pain and dysfunction of the upper arm.
3. Obvious swelling in the local region of upper arm, blisters on the skin and angulation deformity of the arm can be observed. Tenderness in a local area may be found and abnormal movement and bony crepitus may be felt. The affected arm may be shortened if the extent of overlapped displacement is great.
4. When the fracture is complicated by injury of radial nerve, there may occur wristdrop, failure of metacarpophalangeal articulations to stretch out, failure of the thumb to abduct, and skin hypoesthesia or anesthesia on the radial side of the dorsum of the hand.
5. Through roentgenogram the precise site and type of the fracture and the degree of displacement can be confirmed.

Treatment:
Fractures without displacement are treated with splintage for 3 to 4 weeks, while fractures with displacement should be treated with reduction and fixation. In the treatment of fracture of humeral shaft, separated displacement may gradually occur during the period of fixation because of hypertraction, repeated reductions in the patients suffering from transverse or comminuted fracture and with weak constitution, and weak muscular power because of gravity of the arm. If the case is not timely or properly treated, it will lead to slow union or even failure of union of fracture. Therefore, during the treatment, one should pay attention to the prevention of separated displacement of fractured fragments. For the cases of closed fracture complicated by injury of radial nerve, reduction and splintage may be applied, and they will gradually heal in 2 to 3 months.
 
Reduction:
The reduction should be done under analgesia and anesthesia. The patient may take either sitting or horizontal position. One assistant applies upward traction by passing a long strip of cloth under the axilla of the affected shoulder, while the other assistant keeps the forearm at the neutral position to apply downward traction.  Except for the transverse fracture with excessive overlapped displacement, forceful traction should be avoided for fear of hypertraction of the fractured ends. After complete correction of overlapped displacements, the operator can perform manipulative reduction according to the different sites of fracture and displacements.

1. Fracture in the upper one-third: Under the maintenance of traction, the operator presses the lateral side of the distal end of the fracture with his two thumbs and holds in circle the medial side of the proximal end with the rest fingers. Then, he lifts and pulls the proximal end outwards with his two thumbs to form a slightly lateral angulation with the distal end, and pushes the distal end inward, hence, the reduction can be achieved.

2. Fracture in the middle one-third: Under the maintenance of traction, the operator presses the lateral side of the distal end of the fracture with his two thumbs and holds in circle the medial side of the proximal end with the rest fingers. Then, he pushes and presses the proximal end inward with his thumbs, and lifts and pulls the distal end outward with the rest fingers, make sure that efforts should be practiced slowly. The traction can be slowly loosened as a proper meet of the fracture ends is felt. The operator holds the fracture site with the root part of his two palms so as to apply squeezing and pressing manipulations. Then an assistant is asked to rotate the lower part of the fractured end slightly. The reduction can be achieved and is stable when the bone crepition becomes weaker, and finally disappears.

3. Fracture in the lower one-third: An assistant is asked to fix the affected arm in the neutral position and apply slight traction; the operator performs squeezing and pressing manipulations with two hands to make the spiral or oblique sections reposited.

Fixation:
If the fractured shaft remains stable after reduction, then, under the continuous traction, put a cotton pad on the upper arm, and 4 pieces of splints anteriorly, posteriorly, medially and laterally respectively, and tie up with three rounds of tapes. If there still exists slightly lateral or angulation displacement, the pressure fixation with two pads or three pads may be respectively applied to make it gradually reduced. If there is bone fragment that cannot be satisfactorily reduced, a fixed pad can be used to press it gradually back. But it should be noticed that no fixed pad should be put in the region of radial groove, for fear of paralysis of radial nerve due to compression.  

Generally a super-shoulder fixation is needed in the treatment of the fracture in the upper one-third, and a super-elbow fixation is needed in the treatment of the fracture in the lower one-third. After fixation, flex the elbow to the angle of 90°, then, suspend the forearm in front of the chest with neutral position on a wood board. The duration of fixation is 6 to 8 weeks for adults, and 3 to 5 weeks for children. Fractures in the middle one-third are subject to a slow union or nonunion, so the duration should be longer. It is advisable for the case of radial nerve injury to have an early operative exploration if there is no sign for recovery within 4 to 10 weeks.

Functional exercise:
After reduction and fixation, the patient should be encouraged to do fist-clenching exercises so as to promote blood circulation and enhance the fixation of splints. The patient is asked to clench his fist forcefully during the early exercises of his shoulder and elbow joints in order to keep the relative stability of the fractured part. The patient with marked space of transverse fracture is advised, based on the prerequisite for holding up the shoulder, to hold the elbow with his palm to push it slightly upwards or to wrap the shoulder and the elbow with bandages upward and downward. Make sure a precise para-position is done for a quick heal.

Generally, 3 to 4 weeks later, the patient feels to regain his strength and free flexion and extension of elbow joint, which indicates that the fracture has been basically united. Then, the fixation should be further applied for 1 to 2 more weeks. After the fracture is confirmed to have clinically healed by examination, the fixation can be removed, and herbal fumigation and bathing method may be applied in combination with active functional exercises of shoulder and elbow joints.

Herbal therapy
Internal treatment based on syndrome differentiation

1. In the early stage
Main symptoms and signs:
Swelling and pain in the injured arm, epigastric distension and fullness, constipation, deep yellow urine and restlessness.

Therapeutic methods:
Promoting blood flow to remove the stasis, releasing bowel movement to eliminate the accumulation.

Recipe and herbs:
Modified Taoren Chenqi Decoction. Specifically, Shengdahuang (Radix et Rhizoma Rhei) (to be decocted later) 10 g, Taoren (Semen Persicae) 10 g, Poxiao (Sal Glauberis) (to be taken following its infusion with the hot decoction) 12 g, Guizhi (Ramulus Cinnamomi Cassiae) 6 g and Gancao (Radix Glycyrrhizae) 3g.
 
2. In the middle stage
Main symptoms and signs:
Subdued swelling and relived pain, poor appetite, slow healing or failure to heal of fracture.

Therapeutic methods:
Reuniting the bones, muscles and ligaments, and promoting blood flow to remove the stasis.

Recipe and herbs:
Modified Jiegu Xujin Decoction. The herbs see the treatment of clavicular fracture in the middle stage.

3. In the late stage
Main symptoms and signs:
Lassitude of the injured arm, weakness of tendons and bones, emaciation, list lessness, poor appetite and impaired motion of the joint.

Therapeutic methods:
Replenishing qi and nourishing blood.

Recipe and herbs:
Modified Bazhen Decoction. Specifically, Dangshen (Radix Codonopsitis Pilosulae) 10 g, Baizhu ( Rhizoma Atractylodis Macrocephalae) 10 g, Fuling (Sclerotium Poriae Cocos) 10 g, Danggui (Radix Angelicae Sinensis ) 10 g, Shudihuang ( Radix Rehmanniae Praeparata) 10 g, Baishaoyao (Radix Paeonine Alba ) 10 g, Chuanxiong ( Rhizoma Ligustici Chuanxiong)6 g, Jixueteng (Caulis Spatholobi) 10 g, Chenpi (Pericarpium Citri Reticutatae) 10 g, Gancao (Radix Glycyrrhizae) 5 g, Shengjiang (Rhizoma Zingiberis Recens ) 3 pieces, and Dazao (Fructus Ziziphi Jujubae) 2 piece.

External therapy:
In the early stage, Sanse Application may be externally used. In the middle stage, Herbal Plaster for Jiegu may be externally applied. In the late stage, fumigation and bathing may be applied with Shangzhi Sunshang Lotion. Specifically, Shenjincao (Herba Lycopodii Japonici) 15 g, Tougucao (Herba Speranskiae seu Impatientis) 15 g, Jingjie ( Herba Schizonepetae ) 10g, Fangfeng (Radix Ledebouriellae) 10 g, Honghua (Ftos Carthmi) 10 g, Oiannianjian (Rhizoma Homalomenae ) 10 g, Liujinu (Herba Artemisiae Anomalae) 10 g, Guizhi ( Ramulus Cinnamomi Cassiae) 10 g, Sumu ( Lignum Sappan ) 10 g, Chuanxiong (Rhizoma Ligustici Chuanxiong) 10 g and Weilingxian (Radix Clematidis) 10 g. Give the fumigation and bathing 2 to 4 times daily.