Proximal humerus fracture

This page is for adult patients; for pediatric patients see proximal humerus fracture (peds)

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

Clinical Features

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

Differential Diagnosis

Humerus Fracture Types

Humeral anatomy

• Adult
  • Proximal
  • Shaft
  • Distal
    • Capitellum
    • Trochlea
    • Condylar
• Pediatric
  • Proximal
  • Shaft
  • Distal
    • Supracondylar
    • Lateral epicondyle
    • Medial epicondyle

Shoulder and Upper Arm Diagnoses

Traumatic/Acute:

• Shoulder Dislocation
  • Anterior shoulder dislocation
  • Posterior shoulder dislocation
  • Inferior shoulder dislocation
• Clavicle fracture
• Humerus fracture
• Scapula fracture
• Acromioclavicular joint injury
• Glenohumeral instability
• Rotator cuff tear
• Biceps tendon rupture
• Triceps tendon rupture
• Septic joint

Nontraumatic/Chronic:

• Rotator cuff tear
• Impingement syndrome
• Calcific tendinitis
• Adhesive capsulitis
• Biceps tendinitis
• Subacromial bursitis
• Cervical radiculopathy

Refered pain & non-orthopedic causes:

• Referred pain from
  • Neck
  • Diaphragm (e.g. gallbladder disease)
• Brachial plexus injury
  • Rucksack paralysis
• Axillary artery thrombosis
• Thoracic outlet syndrome
• Subclavian steal syndrome
• Pancoast tumor
• Myocardial infarction
• Pneumonia
• Pulmonary embolism

Evaluation

Proximal humerus fracture

• 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

General Fracture Management

• Acute pain management
• Open fractures require immediate IV antibiotics and urgent surgical washout
• Neurovascular compromise from fracture requires emergent reduction and/or orthopedic intervention
• Consider risk for compartment syndrome

Specific Management

• 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
• Sling and swathe splint, or coaptation splint

Disposition

• Outpatient management if closed and distally neurovascularly intact

Specialty Care

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
• 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

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

See Also

• Humerus fracture

References

• Orthobullets