Difference between revisions of "Proximal humerus fracture"
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| + | ''This page is for <u>adult</u> patients; for pediatric patients see [[proximal humerus fracture (peds)]]'' | ||
==Background== | ==Background== | ||
| + | [[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 injury|brachial plexus neurovascular injuries]] |
**45% have nerve injury (axillary most common) | **45% have nerve injury (axillary most common) | ||
| − | *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]] |
| − | |||
==Clinical Features== | ==Clinical Features== | ||
| Line 13: | Line 14: | ||
==Differential Diagnosis== | ==Differential Diagnosis== | ||
{{Proximal arm fracture DDX}} | {{Proximal arm fracture DDX}} | ||
| − | |||
{{Shoulder DDX}} | {{Shoulder DDX}} | ||
| Line 35: | Line 35: | ||
==Management== | ==Management== | ||
| − | + | {{General Fracture Management}} | |
| − | + | ||
| − | + | ===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 | ||
| + | {{Proximal Humerus shaft fracture splint}} | ||
==Disposition== | ==Disposition== | ||
| − | *Outpatient | + | *Outpatient management if closed and distally neurovascularly intact |
===Specialty Care=== | ===Specialty Care=== | ||
| Line 63: | Line 66: | ||
==Complications== | ==Complications== | ||
*Nerve injury | *Nerve injury | ||
| − | **Axillary nerve injury (up to 58%) | + | **[[axillary neuropathy|Axillary nerve injury]] (up to 58%) |
**Suprascapular nerve (up to 48%) | **Suprascapular nerve (up to 48%) | ||
*Avascular Necrosis risk factors | *Avascular Necrosis risk factors | ||
Revision as of 18:50, 28 September 2019
This page is for adult patients; for pediatric patients see proximal humerus fracture (peds)
Contents
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 Fractures
Shoulder and Upper Arm Diagnoses
Traumatic/Acute:
- 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
Refered pain & non-orthopedic causes:
- Referred pain from
- Neck
- Diaphragm (e.g. gallbladder disease)
- Brachial plexus injury
- Axillary artery thrombosis
- Thoracic outlet syndrome
- Subclavian steal syndrome
- Pancoast tumor
- Myocardial infarction
- Pneumonia
- Pulmonary embolism
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
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
References
- Orthobullets