Difference between revisions of "Proximal humerus fracture"

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==Background==
 
==Background==
[[File:Proximal humerus fracture.png|thumb|Proximal humerus fracture]]
+
[[File:Prox humerus fracture.jpeg|thumbnail]]
 
*Typically occur in elderly osteoporotic patients from FOOSH mechanism
 
*Typically occur in elderly osteoporotic patients from FOOSH mechanism
 
*Must rule-out axillary and brachial plexus neurovascular injuries
 
*Must rule-out axillary and brachial plexus neurovascular injuries
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*Greater tuberosity fracture suggests rotator cuff tear
 
*Greater tuberosity fracture suggests rotator cuff tear
 
*Lesser tuberosity fracture suggests posterior shoulder dislocation
 
*Lesser tuberosity fracture suggests posterior shoulder dislocation
[[File:Prox humerus fracture.jpeg|thumbnail]]
 
  
 
==Clinical Features==
 
==Clinical Features==
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==Differential Diagnosis==
 
==Differential Diagnosis==
 
{{Proximal arm fracture DDX}}
 
{{Proximal arm fracture DDX}}
 
 
{{Shoulder DDX}}
 
{{Shoulder DDX}}
  
 
==Evaluation==
 
==Evaluation==
 
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[[File:Proximal humerus fracture.png|thumb|Proximal humerus fracture]]
 
*AP, lateral, and axillary radiographs
 
*AP, lateral, and axillary radiographs
 
*Fracture of articular surface suggested by pseudosubluxation:
 
*Fracture of articular surface suggested by pseudosubluxation:

Revision as of 06:08, 10 May 2019

Background

Prox humerus fracture.jpeg
  • 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 Fractures

Humeral anatomy

Shoulder and Upper Arm Diagnoses

Traumatic/Acute:

Nontraumatic/Chronic:

Refered pain & non-orthopedic causes:

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

    • 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

References

  • Orthobullets