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==
*Typically occur in elderly osteoporotic pts from FOOSH mechanism
 
*Must rule-out axillary and brachial plexus neurovascular injuries
 
*Greater tuberosity fx suggests rotator cuff tear
 
*Lesser tuberosity fx suggests posterior shoulder dislocation
 
 
[[File:Prox humerus fracture.jpeg|thumbnail]]
 
[[File:Prox humerus fracture.jpeg|thumbnail]]
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*Typically occur in elderly osteoporotic patients from FOOSH mechanism
 +
*Must rule-out axillary and [[brachial plexus injury|brachial plexus neurovascular injuries]]
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**45% have nerve injury (axillary most common)
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*Greater tuberosity fracture suggests [[rotator cuff tear]]
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*Lesser tuberosity fracture suggests [[posterior shoulder dislocation]]
  
 
==Clinical Features==
 
==Clinical Features==
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*Arm is held closely against chest wall
 
*Arm is held closely against chest wall
  
==Imaging==
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==Differential Diagnosis==
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{{Proximal arm fracture DDX}}
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{{Shoulder DDX}}
 +
 
 +
==Evaluation==
 +
[[File:Proximal humerus fracture.png|thumb|Proximal humerus fracture]]
 
*AP, lateral, and axillary radiographs
 
*AP, lateral, and axillary radiographs
*Fx of articular surface suggested by pseudosubluxation:
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*Fracture of articular surface suggested by pseudosubluxation:
***Superior joint hematoma pushes humerus down
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**Superior joint hematoma pushes humerus down
 +
*Consider CT for
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**Preop surgical planning
 +
**Greater tuberosity or humoral head position uncertain
 +
**Intra-articular comminution
  
==Differential Diagnosis==
+
===Neer System===
{{Proximal arm fracture DDX}}
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*Proximal humerus is divided into four "parts" based on epiphyseal lines:
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**Articular surface of humeral head
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**Greater tubercle
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**Lesser tubercle
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**Shaft of humerus
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*A "one-part" fracture is one in which fragment is displaced <1cm or not angulated >45deg
  
 
==Management==
 
==Management==
*Guided by the Neer System
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{{General Fracture Management}}
**Proximal humerus is divided into four "parts" based on epiphyseal lines:
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***Articular surface of humeral head
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===Specific Management===
***Greater tubercle
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*Ortho consult in the ED
***Lesser tubercle
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*Elderly patient with comminution, multiple fractures, or poor bone might be candidates for hemiarthroplasty
***Shaft of humerus
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*Improved outcomes if surgery within 14 days
**A "one-part" fx is one in which fragment is displaced <1cm or not angulated >45deg
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{{Proximal Humerus shaft fracture splint}}
*"One-part" fracture:
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**Sling and swathe, ice, ortho referral
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==Disposition==
*More than one-part fractures:
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*Outpatient management if closed and distally neurovascularly intact
**Ortho consult in the ED
+
 
 +
===Specialty Care===
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'''Non Operative'''
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*85% Non-op, often with following features
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**Minimally displaced
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**Located at surgical neck non op if either 1 or 2 part
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**Greater tuberosity fracture with < 5mm displacement
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**Generally, "One-part" fracture of humeral head
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**Consider in advanced age, poor bone quality, non dominant hand, co-morbid disease, other injuries
 +
*Encourage range of motion within 14 days
 +
 
 +
'''Operative'''
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*More than one-part fractures
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*One part fractures of anatomical neck
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*Greater than 45 degree angulation
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*Greater tuberosity > 5mm displaced
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*Fracture of lesser tuberosity
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*"Floating" elbow, where forearm also has fracture
 +
 
 +
==Complications==
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*Nerve injury
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**[[axillary neuropathy|Axillary nerve injury]] (up to 58%)
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**Suprascapular nerve (up to 48%)
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*Avascular Necrosis risk factors
 +
**4 part fractures
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**Head split
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**Short calcar segments
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**Disrupted medial hinge
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*[[Adhesive capsulitis]]
  
 
==See Also==
 
==See Also==
 
*[[Humerus fracture]]
 
*[[Humerus fracture]]
  
==Source==
+
==References==
*Tintinalli
+
*Orthobullets
 
+
[[Category:Orthopedics]]
[[Category:Ortho]]
 

Latest revision as of 18:50, 28 September 2019

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

Background

Prox humerus fracture.jpeg

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

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
  • 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
  • Avascular Necrosis risk factors
    • 4 part fractures
    • Head split
    • Short calcar segments
    • Disrupted medial hinge
  • Adhesive capsulitis

See Also

References

  • Orthobullets