Proximal humerus fracture

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Background

  • Typically occur in elderly osteoporotic patients from FOOSH mechanism
  • Must rule-out axillary and brachial plexus neurovascular injuries
    • 45% have nerve injury (axillary most common)
  • Greater tuberosity fracture suggests rotator cuff tear
  • Lesser tuberosity fracture suggests posterior shoulder dislocation
Prox humerus fracture.jpeg

Clinical Features

  • Pain, swelling, tenderness about the shoulder
  • Arm is held closely against chest wall
Proximal humerus fracture

Differential Diagnosis

Humerus Fractures

Humeral anatomy

Shoulder and Upper Arm Diagnoses

Traumatic/Acute:

Nontraumatic/Chronic:

Refered pain & non-orthopedic causes:

Evaluation

  • AP, lateral, and axillary radiographs
  • Fracture of articular surface suggested by pseudosubluxation:
    • Superior joint hematoma pushes humerus down
  • Consider CT for
    • Preop surgical planning
    • Greater tuberosity or humoral head position uncertain
    • Intra-articular comminution

Neer System

  • Proximal humerus is divided into four "parts" based on epiphyseal lines:
    • Articular surface of humeral head
    • Greater tubercle
    • Lesser tubercle
    • Shaft of humerus
  • A "one-part" fracture is one in which fragment is displaced <1cm or not angulated >45deg

Management

Non Operative

  • 85% Non-op, often with following features
    • Minimally displaced
    • Located at surgical neck non op if either 1 or 2 part
    • Greater tuberosity fracture with < 5mm displacement
    • Generally, "One-part" fracture of humeral head
    • Consider in advanced age, poor bone quality, non dominant hand, co-morbid disease, other injuries
  • Sling and swathe splint, or coaptation splint
  • Encourage range of motion within 14 days

Operative

  • More than one-part fractures
  • One part fractures of anatomical neck
  • Greater than 45 degree angulation
  • Greater tuberosity > 5mm displaced
  • Fracture of lesser tuberosity
  • "Floating" elbow, where forearm also has fracture
    • Ortho consult in the ED
    • Elderly patient with comminution, multiple fractures, or poor bone might be candidates for hemiarthroplasty
    • Improved outcomes if surgery within 14 days

Complications

  • Nerve injury
    • Axillary nerve injury (up to 58%)
    • Suprascapular nerve (up to 48%)
  • Avascular Necrosis risk factors
    • 4 part fractures
    • Head split
    • Short calcar segments
    • Disrupted medial hinge
  • Adhesive capsulitis

Disposition

See Also

References

  • Orthobullets