Proximal humerus fracture: Difference between revisions

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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 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]]
[[File:Prox humerus fracture.jpeg|thumbnail]]


==Clinical Features==
==Clinical Features==
*Pain, swelling, tenderness about the shoulder
*Pain, swelling, tenderness about the shoulder
*Arm is held closely against chest wall
*Arm is held closely against chest wall
[[File:Proximal humerus fracture.png|thumb|Proximal humerus fracture]]


==Differential Diagnosis==
==Differential Diagnosis==
{{Proximal arm fracture DDX}}
{{Proximal arm fracture DDX}}
{{Shoulder DDX}}
{{Shoulder DDX}}


==Diagnosis==
==Evaluation==
[[File:Proximal humerus fracture.png|thumb|Proximal humerus fracture]]
[[File:Prox humerus fracture.jpeg|thumbnail]]
*AP, lateral, and axillary radiographs
*AP, lateral, and axillary radiographs
*Fracture of articular surface suggested by pseudosubluxation:
*Fracture of articular surface suggested by pseudosubluxation:
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==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==
*Outpatient management if closed and distally neurovascularly intact
===Specialty Care===
'''Non Operative'''
'''Non Operative'''
*85% Non-op, often with following features
*85% Non-op, often with following features
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**Generally, "One-part" fracture of humeral head
**Generally, "One-part" fracture of humeral head
**Consider in advanced age, poor bone quality, non dominant hand, co-morbid disease, other injuries
**Consider in advanced age, poor bone quality, non dominant hand, co-morbid disease, other injuries
{{Template:Proximal Humerus shaft fracture splint}}
*Encourage range of motion within 14 days
*Encourage range of motion within 14 days


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*Greater tuberosity > 5mm displaced
*Greater tuberosity > 5mm displaced
*Fracture of lesser tuberosity
*Fracture of lesser tuberosity
*"Floating" elbow, where forearm also has fx
*"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


==Disposition==
==Complications==
*Nerve injury
**[[axillary neuropathy|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==
==See Also==
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==References==
==References==
 
*Orthobullets
[[Category:Orthopedics]]
[[Category:Orthopedics]]

Latest revision as of 21:55, 13 June 2020

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

Background

Clinical Features

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

Differential Diagnosis

Humerus Fracture Types

Humeral anatomy

Shoulder and Upper Arm Diagnoses

Traumatic/Acute:

Nontraumatic/Chronic:

Refered pain & non-orthopedic causes:

Evaluation

Proximal humerus fracture
Prox humerus fracture.jpeg
  • 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