It is important to obtain a comprehensive history. This should consider not only the mechanism of the injury and additional injuries, but also any comorbidities, activity level and personal needs.
2. Clinical examination
Examine the upper arm (also posteriorly and medially) for:
Neurologic or vascular deficit (especially radial nerve)
Evaluation and documentation of the radial and posterior interosseous nerves for a “primary nerve injury” is essential before any reduction maneuver.
An adjacent wound implies an open fracture, which needs urgent surgical debridement.
3. Open fractures
Open fractures in the humeral shaft frequently demand a special procedure depending on the severity of the soft tissue injury. Be aware of additional neurovascular injuries.
This influences not only the timing of surgery, but also the approach, the type of fracture fixation and soft tissue management. A staged approach is frequently useful, including an early second look after initial external fixation, local debridement and soft tissue closure using vacuum sealing.
4. Radiological examination
Take x-ray images in two perpendicular planes showing the entire humerus including the adjacent joints. This allows for assessment of longitudinal and rotational alignment.
If the fracture extends into the shoulder or elbow joints, consider additional imaging. This should include at least x-ray images in two perpendicular planes of the affected joint and if in any doubt additional CT scans with or without surface/volume rendering.
5. Further investigation
If there is concern about neurological or vascular injury, see the corresponding additional material.